HX64057453 
RD137  G12  X-ray  observations  f 


RECAP 

OBSERVATIONS 
FOR  FOREIGN  BODIES 
and  their  LOCALISATION 


BY 


HAROLD  C.  GAGE 


C.  V.  MOSBY  COMPANY, 


ST.  LOUIS 


RDI37  GIZ 

CoUcge  ot  pfjpsiciansf  anb  burgeons 
liifytavp 


D  R.  Mary  L.H.A.Snow 


X-RAY  OBSERVATIONS 
FOR  FOREIGN  BODIES 
and  their  LOCALISATION 


To 

M.  le  Docteur  Beclere  de  rAcademie  de  Medecine,  Chef  du  Service 

Central  de  Radiologie  du  Gouvernement  Militaire  de  Paris. 

In  appreciation  of  the  X-ray  Service  of  the  French  Army,  and  of  much 
personal  kindness  and  encouragement. 


X-RAY   OBSERVATIONS 
FOR    FOREIGN    BODIES 

and  their  LOCALISATION 


BY 

Captain  HAROLD  C.  GAGE,  A.R.C,  O.I. P. 

CONSULTING  RADIOGRAPHER  TO  THE  AMERICAN  RED  CROSS 
HOSPITAL  OF  PARIS  ;  ^  RADIOGRAPHER  IN  CHARGE,  MILITARY 
HOSPITAL  V.R.  76,  RIS    ORANGIS,  AND    COMPLEMENTARY    HOSPITALS 


ST.   LOUIS 
C.   V.   MOSBY   COMPANY 

1920 


Printed  in  Great  Britain 


Serial  N°  R. 275 
Cross  section  /eve/s 


Sect/on  2d 


Section  31. 


^.C.?. 


COMBINED    LOCALISATION    AND    RECONSTRUCTION    OF    THE 
WOUND   TRACT. 

The  passage  of  the  projectile  is  marked  in  each  section  by  the  thick  line 
indicating  the  tissues  and  organs  probably  injured.    The  subsequent  history 
of  the  patient  gives  the  following  :   Empyema,  subphrenic  and  perirenal 
abscess,  duodenal  fistula  and  urinary  fistula. 
Frontis{iece 


PREFACE 

This  small  contribtttion  to  IVar  Radiology  was  written  by 
inviiation  in  June,  1(^17.  It  ivas  to  have  been  a  chapter  on 
the  localisation  of  foreign  bodies  in  a  ivork  that  was  being 
compiled  for  the  American  Council  of  National  DefencCy 
but  owing  to  the  death  of  the  Editor  the  publication  was 
abandoned.  The  matter  remains  unchanged^  with  the 
exception  of  some  stnall  additions  and  appendices. 

The  Hospital  at  Ris  Orangis  has,  during  i<^ij  and  igi8y 
been  largely  used  as  a  training  centre,  and  it  is  in  response  to 
the  requests  of  many  visitors  to  the  clinic  that  the  book  is  now 
published.  It  formed  the  basis  of  the  lectures  given  on  the 
subject. 

These  observations  are  based  on  the  personal  experience 
of  the  Author  ivith  the  methods  referred  to  in  this  book,  con- 
stituting over  4.  years  application  to  the  problems  of  war 
radiology  (the  first  seven  months  were  passed  in  an  advanced 
ambidance  within  three  miles  of  the  line,  the  remainder 
has  been  spent  at  the  base,  apart  from  visits  of  detached 
duty),  but  for  the  majority  of  them,  no  originality  is  claimed; 
and  it  is  impossible  to  give  personal  acknowledgment  to  all 
who  have  generously  helped  rne,  or  to  the  originator  and 
every  method  mentioned.  I  should  like,  however,  to  acknow- 
ledge the  great  kindness  and  courtesy  shown  to  me,  and  the 
information  and  experience  so  freely  placed  at  my  disposal,  by 
my  French  colleagues.  It  is  largely  owing  to  their  keen 
appreciation  of  the  questions  involved,  and  their  unwearied 
application  to  the  solution  of  the  problems  presented,  that  much 
"progress  has  been  made. 

To  Dr.  Belot  and  Dr.  Fraudet  I  am  indebted  for  the  privilege 
of  inserting  their  method  of  localisation  of  foreign  bodies  in  the 
eye,  from  their  original  work  in  the  '^Journal  de  Radiologic  et 
d  Electrotherapies ' 

To  Mr.  H.  Franze  my  thanks  are  due  for  the  excellent 
drawing  of  many  of  the  illustrations ;  also  to  my  assistants, 
Mr.  Beer,  who  provided  several  of  the  illustrations,  and  Miss 
Slater,  zvhose  help  in  revising  the  MS.  has  been  invaluable. 


INTRODUCTION 

It  is  almost  superfluous  to  state  that  accurate  localisation  of 
foreign  bodies  is  of  prime  necessity  to  the  surgeon  who  is  to 
remove  them.  No  one  realises  this  more  than  the  surgeon 
who  has  wandered  through  the  tissues  in  a  fruitless  search  for 
a  foreign  body  which  he  knows  is  somewhere  there,  but  the 
exact  location  of  which  has  not  been  made  clear  to  him.  In 
other  words,  a  localisation,  to  be  practical  and  successful,  must 
not  only  be  accurate  but  must  have  been  recorded  on  the 
patient  in  such  a  manner  as  to  be  clear  to  the  surgeon  as  well 
as  to  the  radiographer.  Moreover,  it  is  quite  essential  that  the 
surface  marks  from  which  the  foreign  body  is  oriented  be  so 
situated,  and  of  such  number  as  to  obviate,  in  so  far  as 
possible,  the  errors  that  may  arise  from  the  impossibility  of 
re-establishing  on  the  operating  table  the  exact  position 
occupied  by  the  limb  or  body  during  localisation  on  the  X-ray 
table.  For  example,  a  report  from  the  radiographer  that  the 
foreign  body  lies  so  many  centimetres  below  a  mark  on  the 
skin  is  insufficient,  and  to  a  certain  degree  dangerous,  in  that  it 
affords  an  inexperienced  surgeon  an  unjustifiable  confidence 
in  his  ability  to  find  it.  The  additional  four  or  five  minutes  on 
the  X-ray  table  needed  to  record  a  localisation  from  which  a 
surgeon  may  work  with  certainty  are  much  better  spared  tha  n 
a  longer  time  spent  by  the  operating  team  in  an  ill-directed 
search — not  to  mention  the  consequent  unnecessary  mutilation. 

Two  years  experience  with  the  exceedingly  simple  and 
ingenious  method  of  Localisation  by  Three  Intersecting  Lines, 
developed  and  perfected  by  Mr.  Gage,  has  convinced  the 
writer  that  it  is  the  most  practicable  for  the  majority  of  cases. 
The  three  lines  joining  the  three  pairs  of  marks  on  the  skin  are 
readily  pictured,  and  the  position  and  relations  of  the  foreign 
body  consequently  more  clearly  visualised  than  is  possible  by 
any  other  system.  While  mechanical  aids  may  be  used  in 
addition  they  are  very  rarely  necessary,  which  adds  greatly  to 
the  practicability  of  the  method  for  institutions  where  the  cost 
of  such  apparatus  would  not  warrant  its  possession.  A  proof 
of  the  value  of  the  method  is  the  remarkable  record  made  by 
it  in  the  hospital  at  Ris  Orangis.     A  total  of  306  localisations 


Introduction 

resulted  in  302  successful  removals  ;  in  two  cases  the  search 
was  abandoned  on  account  of  the  danger  of  wounding 
important  anatomical  structures,  and  only  two  localisations 
were  unsuccessful. 

Mr.  Gage's  experience,  his  great  skill,  and  his  knowledge  of 
physical  problems,  lend  great  weight  to  his  remarks  and 
observations.  No  one  can  realise  this  more  than  those  who, 
like  the  writer,  have  had  the  great  privilege  and  the  pleasure 
of  working  with  him. 

JOSEPH  A.  BLAKE, 
Colonel,  Medical  Corps,  U.S.A. 


X-RAY   OBSERVATIONS   FOR   FOREIGN 
BODIES     AND     THEIR     LOCALISATION 

General  Installation. 
The  equipment  for  the  generation  of  the  electric  current 
necessary  to  operate  the  X-ray  tube  for  locaHsation  of  foreign 
bodies  needs  nothing  special  beyond  the  requisites  for  or- 
dinary radiography  and  fluoroscopy.  If  the  opportunity  for 
choice  occurs  a  coil  outfit  should  be  selected,  as  it  un- 
doubtedly has  points  in  its  favour  for  use  in  the  field  as  against 
the  high  tension  transformer.*  For  general  hospital  work, 
where  instantaneous  pictures  of  organs  in  motion  are  a  daily 
necessity,  the  latter  is  indispensable,  but  the  percentage  of  this 
work  is  almost  nil  in  war  surgery. 

The  coil  should  be  given  preference,  briefly  for  the  follow- 
ing reasons:  it  is  easily  portable,  and  gives  better  screen 
illumination  for  a  given  milliampereage,  with  a  diminished  risk 
•of  burns  to  both  patient  and  operator;  the  proportion  of 
fluoroscopic  examinations  is  much  greater  than  that  of  plates. 

Details  needing  special  attention  apart  from  the  instrumenta- 
tion of  any  given  method  of  localisation  are:  first,  a  rigid 
X-ray  table,  with  a  convenient  under-table  trolley  to  carry  the 
tube  in  a  well  protected  shield  or  box,  and  giving  longitudinal 
and  cross  displacement  that  can  be  definitely  controlled  and 
measured;  second,  and  almost  first  in  importance,  the  tube 
holders  must  be  such  as  to  give  convenient  means  of  exactly 
centering  the  tube  to  a  mechanical  closing  diaphragm  that  shall 
-close  absolutely  in  a  central  position.  While  many  other 
desirable  features  might  be  added,  these  are  imperative,  and 
with  them  the  most  exacting  work  can  be  done  with  absolute 
certainty. 

*  The  advent  of  the  new  radiator  self-rectifying  Coolidge  tube  and  the 
American  Army  Portable  Unit,  is  such  an  advance  as  to  constitute  a 
xevolution  in  X-ray  apparatus  ;  its  simplicity,  efficiency,  and  portability  are 
.such  that  it  may,  and  probably  virill,  supplant  the  coil. 


2  X-Ray  Observations  for  Foreign  Bodies 

Darkening  the  Room. 

Where  possible  ample  room  should  be  provided  for  the 
X-ray  department.  The  tendency  is  to  give  any  small  odd 
room  over  to  this  work,  which  can  but  cripple  the  efficiency 
to  a  serious  extent.  In  the  X-ray  room,  work  has  to  be  done 
of  the  most  tedious  and  exacting  nature,  which  under  un- 
favourable conditions  becomes  intolerable  and  shows  itself  in 
the  results.  Let  it  not  be  forgotten  that  the  X-ray  department 
in  war  surgery  is  second  in  importance  to  nothing  in  the  whole 
hospital,  and  its  quarters  must  be  good,  airy,  and  spacious; 
many  people  must  work  there;  patients  are  frequently  very 
sick,  and  the  wounds  smell  badly;  besides,  the  room  is  often 
required  for  an  operating  room  for  removal  of  foreign  bodies 
under  screen  control,  and  for  the  reduction  of  fractures. 

Darkening  and  ventilation  are  difficult  problems,  but  for 
the  sake  of  efficiency  they  must  be  solved.  The  window 
should  always  be  accessible  to  be  thrown  open  for  airing 
between  cases,  while  the  operator  wears  coloured  spectacles 
to  preserve  the  adaptation  of  his  eyes.  The  artificial  lighting 
should  be  under  control  by  a  small  resistance,  in  order  that 
while  changing  position  of  the  patient,  etc.,  it  may  be  dimin- 
ished to  a  minimum  ;  it  should  be  preferably  of  red  or  violet 
colour.  In  advanced  field  use  the  cryptoscope  is  invaluable,, 
and  its  best  form  will  be  described  later.  But  whether  the 
cryptoscope  is  used  or  the  room  darkened,  care  must  be  takew 
that  not  one  penetrating  ra}^  can  enter,  in  order  that  in  a 
foreign  body  examination  the  smallest  fragment  may  not  be 
missed. 

Protection. 

This  must,  of  course,  be  efficient.  First  see  that  the  tube  is 
enclosed  in  a  ray-proof  cupule  or  box,  which  the  radiographer 
should  test  personally  with  the  screen  and  if  necessary 
reinforce.  To  test  the  lead  glass  of  a  fluorescent  screen,  should 
a  second  screen  not  be  at  hand,  project  the  rays  through  the 
glass,  and  if  fluorescence  is  produced  discard  for  a  denser 
glass  or  add  a  second.  Handle  covers  and  gloves  should  be 
lined  and  not  made  of  plain  lead  impregnated  rubber.      Work 


X-Ray  Observations  for  Foreign  Bodies  3 

with  as  small  a  diaphragm  opening  as  possible  ;  do  not  place 
yourself  or  your  hngers  in  the  direct  beam,  and  you  are  safe. 

Diaphragm. 

The  type  to  be  preferred  is  one  that  closes  with  one 
controlling  handle  and  always  on  its  exact  centre.  It  should 
close  with  ease  in  order  that  the  tube  may  not  be  displaced  at 
the  same  time.  It  will  be  found  that  few,  if  any,  of  these 
diaphragms  are  in  themselves  efficient  ;  they  are  always  flat, 
and  as  hard  penetrating  rays  are  mostly  used,  many  secondary 
rays  are  generated,  producing  diffusion  and  spoiling  the 
definition  ;  consequently,  it  will  be  found  of  infinite  advantage 
to  provide  in  addition  a  simple  cylindrical  diaphragm  mounted 
on  sheet  lead  to  place  over  the  mechanical  one.  Provide  a 
cylinder  of  the  smallest  diameter  that  will  suit  you,  and  you 
will  be  amply  repaid  in  the  clear  definition  and  in  the  assurance 
that  you  are  letting  nothing  pass. 

The  Tube. 

Although  in  some  localising  methods  it  is  preferable  to  use 
the  overhead  tube  or  vertical  screening  stand,  much  of  the 
work  will  be  carried  out — general  screening,  operating  with 
fluoroscopic  aid,  etc. — in  the  horizontal  position  with  the 
under-table  tube.  The  choice  of  the  tube  is  of  some  importance; 
therefore  let  it  be  a  well  formed,  flexible  tube,  preferably 
water  cooled,  for  it  is  worth  much  during  an  operative  pro- 
cedure to  be  relieved  of  all  anxiety  as  to  its  welfare  and 
efficiency.  When  formed,  guard  it  and  nurse  it  well.  The 
focus  need  not  be  of  the  sharpest,  but  must  not  be  too  wide. 
In  choosing  a  tube,  should  it  not  centre  well,  discard  it,  as  it 
will  lead  to  inaccuracy  and  disappointment.  See  always  that 
its  anticathode  and  anode  are  not  accidentally  disconnected,  or 
its  wandering  focus  will  lead  to  confusion.  A  foot  switch 
control  is  almost  indispensable  and  may  save  you  many  steps 
and  tubes. 

The  penetration  of  the  tube  for  general  observation  should 
be  represented  by  a  spark  gap  of  about  5)^  to  6  in.,  although 
a  softer  degree  will  give  better  contrasts,  and  a  7  and  8  in. 


4  X-Ray  Observations  for  Foreign  Bodies 

gap  may  be  required  in  observations  for  foreign  bodies 
superimposed  on  the  vertebrae,  and  for  examination  of  stout 
patients.  An  adjustable  series  spark  is  a  valuable  addition  for 
regulating  the  tube  penetrations  and  should  always  be  fitted 
to  the  apparatus. 

Foreign  Bodies — Their  Nature  and  Shadow. 
The  visibility   of   a  foreign   body    by  X   rays  on   plate    or 


Illustration  I. 

Radiographic  appearance  of  wood  in  the  soft  tissues  of  the  thigh. 

Equivalent  spark  gap  2  inches,  4  milliamp. -minutes. 

screen  is  (apart  from  its  size)  entirely  a  question  of  its  atomic 
weight,  in  contrast  to  that  of  the  tissues  in  which  it  rests.  For 
this  reason  different  metals  and  materials  throw  a  different 
degree  of  shadow.  It  must  also  be  noted  that  change  in  the 
penetration  of  the  tube  will  change  the  apparent  density  of  a 


X-"Ray  observations  for  Foreign   Bodies  5 

given    material.       This   is   valuable   in   the   differentiation   of 
calcified  glands,  superimposed  bones,  bone  fragments,  etc. 

Pieces  of  shell,  shrapnel  balls  and  rifle  bullets,  nails  and 
metallic  refuse  from  hand  grenades,  and  lead  splutterings  will 
be  easily  detected,  while  thin  bullet  casing  and  fragments  of 
aluminium  are  more  difficult — the  latter  almost  im.possible  if 


"% 


ERRATUM 

P jge  5,  third  line  from  bottom,  should  read 
"Wood,  not  frequently  present,  etc," 
instead  of  "  Wood,  not  infrequently 
present." 


Illustration  2» 
The  casing  of  a  rifle  bullet  stripped  and  remaining  in  the  tissues. 


not  of  considerable  size  and  in  a  thin  part  of  the  body. 
Clothing  throws  no  shadow  unless  it  is  impregnated  Jwith 
some  denser  material.  Wood,  not  infrequently  present  in  the 
soft  tissues,  is  not  discoverable  with  the  screen,  but  may  be 
found  by  plating,  if  the  tube  is  of  low  penetration.  (Illustra- 
tion I.) 


4  X-Ray  Observations  for  Foreign  Bodies 

gap  may  be  required  in  observations  for  foreign  bodies 
superimposed  on  the  vertebrae,  and  for  examination  of  stout 
patients.  An  adjustable  series  spark  is  a  valuable  addition  for 
regulating  the  tube  penetrations  and  should  always  be  fitted 
to  the  apparatus. 

Foreign  Bodies — Their  Nature  and  Shadow. 
The  visibility   of   a  foreign   body    by  X   rays  on   plate    or 


pp 

'^^^^^^1 

' 

Illustration  I. 

Radiographic  appearance  of  wood  in  the  soft  tissues  of  the  thigh. 
Equivalent  spark  gap  2  inches,  4  milliamp.-minutes. 

screen  is  (apart  from  its  size)  entirely  a  question  of  its  atomic 
weight,  in  contrast  to  that  of  the  tissues  in  which  it  rests.  For 
this  reason  different  metals  and  materials  throw  a  different 
degree  of  shadow.  It  must  also  be  noted  that  change  in  the 
penetration  of  the  tube  will  change  the  apparent  density  of  a 


X-"Ray  observations  for  Foreign   Bodies  5 

given    material.       Tills   is   valuable   in   the   differentiation    of 
calcified  glands,  superimposed  bones,  bone  friigments,  etc. 

Pieces  of  shell,  shrapnel  balls  and  rifle  bullets,  nails  and 
metallic  refuse  from  hand  grenades,  and  lead  splutterings  will 
be  easily  detected,  while  thin  bullet  casing  and  fragments  of 
aluminium  are  more  difficult — the  latter  almost  im.possible  if 


Illustration  2. 
The  casing  of  a  rifle  bullet  stripped  and  remaining  in  the  tissues. 

not  of  considerable  size  and  in  a  thin  part  of  the  body. 
Clothing  throws  no  shadow  unless  it  is  impregnated  iwith 
some  denser  material.  Wood,  not  infrequently  present  in  the 
soft  tissues,  is  not  discoverable  with  the  screen,  but  may  be 
found  by  plating,  if  the  tube  is  of  low  penetration.  (Illustra- 
tion I.)  , 


6  X-Ray  Observations  for  Foreign  Bodies 

General  Examinations. 

The  search  for  foreign  bodies  should  not  be  confined  to 
the  region  of  the  wound,  but  a  thorough  general  examination 
should  be  made,  especially  if  there  is  only  one  wound,  i.e.^  the 
wound  of  entrance.  Never  be  led  to  suppose  that  a  wound 
of  exit  negatives  the  possibility  of  a  lodged  foreign  body. 
Many  bullets  strip  their  jackets  in  transit  (Illustration  2),  or 


Illustration  3. 

Sinus  injection  with  bismuth  simulating  a  lead  foreign  body  with 

splutterin^s. 

shell  fragments  are  separated  by  contact  with  bony  structures. 
A  foreign  body  may  travel  a  great  distance  and  take  a  very 
unusual  course.  In  a  case  with  a  wound  of  entrance  over 
the  left  deltoid,  a  shrapnel  ball  was  recovered  from  the 
superficial  tissues  of  the  left  buttock,  having  traversed  the 
length    of   the  body  externally   to  the    ribs.     The    case  was 


X-Rav  Observations  for  Foreio;n  Bodies 


to' 


reported  negative   for    foreign    bodies    on    several  occasions. 
Ultimately  the  ball  manifested  itself  by  causing  an  abscess. 

In  the  examination  for  foreign  bodies  errors  easily  occur, 
■due  to  buttons  on  the  clothing,  coins  or  articles  in  the 
pyjamas  pocket  or  round  the  neck,  pins,  etc.,  in  dressings,  or 
■drains.  Therefore  all  gowns  should  be  tied  with  tape,  and 
dressings  be  fixed  with  adhesive,  or  the  parts  absolutely 
■denuded.  Bone-plates  fixing  fractures,  wire  sutures,  and 
Murphy's  buttons  must  not  be  confused,  and  accumulations 
of  metallic  ointment,  iodoform,  or  bismuth  paste,  show  a 
very  decided  shadow  easily  misinterpreted.     (Illustration  3.) 

Photographic  Faults. 

When  reading  plates,  one  must  bear  in  mind  photographic 
faults  caused  by  air  bubbles  in  development  or  imperfections 
in  the  emulsion  ;  flaws  in  intensification  screens  can  be  a 
further  source  of  error. 

Anatomical  Densities. 

Attention  should  be  given  to  the  possibilities  of  either 
fluoroscopic  or  radiographic  misinterpretation  of  the  shadow 
cast  by  calcified  glands,  gall  stones,  stones  in  the  kidney 
ureter  and  bladder,  phleboliths,  or  superimposed  bones,  such 
as  the  pisiform,  the  spinous  processes  of  the  vertebrce, 
rsesamoids,  the  superior  margin  of  the  acetabulum,  etc.,  but 
with  care  these  can  be  differentiated  by  their  comparative 
■densities.  When  the  fluoroscopic  examination  is  uncertain  a 
plate  should  be  taken.  With  organs  in  motion,  when  it  is  not 
possible  to  take  instantaneous  radiographs,  fluoroscopic 
observations  are  more  reliable. 

Tube  Centering.* 

In  all  radiographic  technique  the  position  of  the  tube  in 
relation  to  patient  and  plate  is  very  important.  In  no 
instance  is  it  more  so  than  in  localising  foreign  bodies,  to 
accomplish  w^hich  it  is  necessary  to  isolate  and  use  the  central 
vertical  beam  of  rays  (or  normal  ray,  as  it  is  termed)  ;  and  at 
*  Archives  of  Radiology  and  Elcdrothciapy,  May,  1918. 


8 


X-Ray  Observations  for  Foreign  Bodies 


times,  to  note  its  incidence  on  the  plate,  screen,  or  patient. 
Most  modern  tube  carriers  and  diaphragms  have  a  mechanical 
attachment,  which  enables  this  adjustment  to  be  made  with 
ease.  By  this  appliance  the  tube  can  be  moved  in  any 
direction,  until  it  is  so  placed  that  the  normal  ray  passes 
through  the  centre  of  the  diaphragm. 

Illustration  4,  Fig  i,   shows  (a)  the  anticathode,   (b  c)  the 
normal  ray  passing  through  (m)  a  tube,  in  which  are  (77,  n'). 


Fu3     I 


Fcfl  3 


X    ' 


f^^ 


^A> 


mm 


^fr 


Illustration  4. 

two  sets  of  cross  wires,  and  {F.S.)  a  small  fluorescent  screen. 
(/)  Shows  the  appearance  on  the  screen  when  the  tube  has 
been  accurately  centered,  the  shadows  of  the  two  crosses 
being  superimposed  on  the  screen  and  forming  one  image 
only  ;  {g)  illustrates  the  screen  appearance  before  centering. 
When  centered,  the  apparatus  (m)  is  removed  and  replaced  by 
the  diaphragm  (/?)  (Fig.  2),  which  closes  down  on  the   same 


X-Ray   Observations  for  Foreign  Bodies  9 

centre.  Fig.  3  shows  a  convenient  method  of  centering  an 
under-table  tube  or  verifying  its  correctness.  On  the  table 
top  is  placed  a  small  papier  mache  box  (a  lady's  powder  pufT  box 
will  do  well),  across  the  top  of  which  two  wires  are  stretched 
at  right  angles,  while  from  their  intersection   hangs   a  smalt 


Illustration  5. 

a,  Anticathode  of  tube.  6,  Path  of  normal  ray.  ni  i?,Cupule  and  dia- 
phragm in  position.  ,ij,  A  disc  of  cardboard,  aperture  in  the  centre  I  in.  in 
diameter.  /,  A  smaller  disc,  with  tiny  central  perforation,  and  second 
hole  for  the  return  of  the  cord  supporting  the  plumb-bob  /.  In  use  the 
tube  stand  is  adjusted  until  the  cord  hangs  in  the  centre  of  the  perforation 
k,  when  the  plumb-bob  may  be  lowered  and  the  incidence  of  the  normal 
ray  recorded.  This  simple  contrivance  can  be  left  attached,  the  metal 
portion  withdrawn  to  the  side  during  exposure. 

plumb-bob  on  a   fine  cord   dipping  into  oil,  with  which   the 
box  is  partially  tilled.     If  the  tube  is  now  brought  under  this- 


10         X-Kay  Observations  for  Foreign  Bodies 

small  contrivance,  and  its  projection  on  the  screen  viewed  with 
the  diaphragm  closed  down,  a  correctly  centered  tube  will  give 
the  appearance  shown  at  O,  while  a  badly  centered  tube  that 
shown  ^iK.  It  is  impossible  to  give  too  much  emphasis  to  the 
importance  of  accurate  centering. 

When  it  is  desirable  to  record  on  a  plate  or  limb  the  inci- 
dence of  the  normal  ray,  or  to  adjust  cross  wires  to  it,  when 
using  the  overhead  tube,  two  pieces  of  cardboard  and  a  plumb 
line  will  suffice  admirably.  Illustrations  5  and  6  show  their 
preparation  and  adjustment. 


Fig.  I.  Fi3.  2 

Illustration  6. 
Vertical  and  lateral  adjustment. 


Provisional  Localisation  at  First  Observation. 

When  a  foreign  body  is  found,  the  diaphragm  should  be 
closed  down,  and  the  adjustment  made  to  include  the  foreign 
body  in  the  narrow  beam  of  rays  projected  vertically  from  the 
lube.  A  small  metallic  circle  on  the  end  of  a  wooden  handle 
may  now  be  inserted  under  the  screen  until  its  image  is  pro- 
jected as  encircling  the  foreign  body;  the  skin  may  be  marked 
through  this  ring  with  an  indelible  pencil,  and  the  ring  with- 


X-Ray  Observations  for  Foreign  Bodies         1 1 

<lra\vn;  or  if  desired,  one  of  the  mechanical  apphances  shown 
in  Ilkistration  7  can  be  used.  This  gives  a  point  on  the  skin 
vertically  over  the  foreign  body.  To  ascertain  its  depth  a 
metal  rod  may  now  be  taken  ;  the  spark  gap  indicator  will  do 
well.  The  rod  is  held  horizontally,  and  its  point  is  placed 
upon  the  spot  previously  marked.  The  diaphragm  should  now 
be  opened  and  the  metal  rod  lowered  across  the  limb,  keeping 
its  point  in  contact  with  the  circumference.  Now  displace 
the  tube  longitudinally  and  the  shadows  of  the  foreign  body 
and  the  point  of  the  rod  will  travel  in  the  opposite  direction; 
if  they  both  travel  the  same  distance  the  point  of  the  rod  is  at 
the  depth  of  the  foreign  body,  and  its  position  can  be  marked 
on  the  skin  as  before  ;  should  the  foreign  body  travel  further  it 
is  necessary  to  lower  the  rod  still  further  till  the  displacement 


Illustration  7. 

A.  Pneumatic  marker  (Hernaman-Johnson),  Watson.  London. 

B.  Mechanical  marker— Gaiffe,  Paris. 

IS  equal.  Care  should  be  taken  to  have  the  screen  horizontal, 
and  to  move  the  rod  in  a  plane  perpendicular  to  the  line  of 
displacement  of  the  anticathode.  In  this  crude  manner  it  is 
possible  to  give  the  approximate  position  of  superficial  foreign 
bodies  for  removal  with  the  vibrator,  or  to  decide  the  necessity 
for  exact  localisation.  The  process  takes  but  a  few  seconds. 
To  measure  the  distance  travelled  by  the  shadows  a  sheet  of 
celluloid,  ruled  in  narrow  lines,  may  be  placed  on  the  fluor- 
escent screen.     In  this  way  a  reliable  guide  is  furnished. 

Another  screen  method,  which  gives  a  rapid  and  accurate 
measure  of  the  depth  of  a  foreign  body,  is  that  of  Strohl.  The 
necessary  apparatus  can  be  improvised  with  very  little  trouble, 
and  is  especially  suitable  for  use  at  a  casualty  clearing  station, 


12         X-Ray  Observations  for  Foreign  Bodies 


where  a  large  number  of  cases  must  be  dealt  with  in  the 
minimum  time.  All  that  is  required  is  a  pair  of  fine  parallel 
wires,  mounted  on  the  upper  surface  of  the  mechanical 
diaphragm  of  the  under-table  tube,  at  equal  distances  from  the 
centre,  and  lying  across  the  most  convenient  line  of  displace- 
ment of  the  tube.     (If  the  wires  are_^ fixed  across  a  broad  strip. 


Figl 


N?. 


-^n/ 


Posifien.  A  P.  aa/iene. 
MtrHs.  Antenon 


=1=3 


Illustration  8. 
of  adhesive  tape,  they  can  be  mounted  and  dismounted  at  any 
time  in  a  few  moments.)  To  simplify  the  calculation  of  the 
depth  of  the  foreign  bod}^,  it  is  most  convenient  to  make  the 
distance  apart  for  the  wires  half  the  height  from  the  anti- 
cathode  to  the   diaphragm  (see  Illustration  8,  Fig.   i,  where 


X-Ray  Observations  for 


Foreign 


Bodies 


13 


X3 


14         X-Ray  Observations  for  Foreign  Bodies 

JVj  IV2  is  half  A  N)  ;  this  distance  should  be  found  as 
accurately  as  possible  by  measurement.  To  test  the  adjust- 
ment, place  the  screen  S  over  the  tube,  and  measure  the 
distance  P^  P2  between  the  shadovs  of  the  two  wires.  Then 
raise  the  screen  through  a  carefully  measured  height  /?,  and 
note  the  new  distance  Q^  Q2  between  the  shadows.  As  will 
be  seen  at  once,  from  the  similarity  of  the  triangles  A  IV^  A^, 
Pi  Qi  ^^>  the  difference  Q^  Q2 — Pi  P2  should  be  exactly  half  h. 
If  it  is  less  than  half  k,  the  wires  should  be  separated  ;  if  it  is 
more  they  must  be  brought  nearer  together,  until,  on  testing 
as  before,  the  adjustment  is  found  to  be  correct. 

In  using  the  apparatus,  the  foreign  body  {F,  Fig.  2)  is  first 
found  with  a  small  diaphragm  opening,  and  the  tube  is 
shifted  until  the  normal  ray  passes  through  it ;  the  point 
of  emergence  is  then  marked  on  the  skin.  If  it  can  con- 
veniently be  done,  the  screen  is  brought  close  down  to  the 
skin  (in  this  position  the  marking  is  facilitated  if  a  perfoi'ated 
screen  is  used).  The  diaphragm  is  then  opened  and  the  tube 
shifted  until  the  shadow'  of  one  of  the  wires  (/^i,  Fig.  2)  passes 
through  a  definite  point  in  the  foreign  body,  and  the  position 
of  this  shadow  (G)  is  marked  on  the  glass  of  the  screen  with 
ink  or  a  grease  pencil.  The  tube  is  shifted  and  the  shadow^ 
of  the  second  wire  {JV2)  made  to  pass  through  the  same  point 
of  the  foreign  body  ;  this  second  position  (//)  is  marked  on 
the  screen  as  before.  Then  the  depth  of  P  below  the  sci'een 
is  twice  the  distance  G  H. 

If  it  is  not  feasible  to  bring  the  screen  into  contact  with 
the  surface  of  the  limb  at  the  point  of  emergence  of  the 
normal  ray  through  F,  the  best  method  is  to  place  a  small 
metallic  body  at  this  point  (see  M,  Fig.  3),  so  that  the 
shadows  of  F  and  M  are  exactly  superposed.  Then,  by 
shifting  the  tube  as  before,  the  points  on  the  screen  where  the 
shadows  of  the  wires  pass  through  M  are  marked,  as  was 
previously  done  for  F ;  the  distance/ A'  is  also  measured  and 
subtracted  from  G  H\  this  difference  multiplied  by  2  is  the 
depth  of  F  below  M,  i.e.,  below  the  marked  point  on  the  skin. 

Fig.  4  (Illustration  8)  shows  a  chart  prepared  in  this  way, 
where  four  different  foreign  bodies  in  the  region  of  the  hip  are 


X-Ray  Observations  for  Foreign   Bodies         15 

clearly  shown,  with  their  respective  depths.      Such  a  chart  is. 
best  made  on  celluloid,  as  explained  below. 

Stereoscopic  Tracings  from  the  Screen. 

Such  tracings  are  easily  made.  Of  course  they  are  not  sO' 
good  as  plates,  but  if  from  pressure  of  work,  or  for  any  other 
reason,  plates  cannot  be  taken,  and  the  relation  of  a  foreign 


Illustration  g. 

The  tube  is  in  position  for  antero-posterior  plating;   it  easily  slides  out 

and  into  the  lateral  position. 

body  is  desired  to  some  bony  landmark,  this  procedure  can 
be  used  to  advantage. 

The  tracings  are  drawn  on  celluloid,  as  previously  described-; 
the    usual    stereoscopic     displacement   of    the    tube    is    made: 


1 6         X-Rav  Observations  for  Foreign  Bodies 


fe' 


between  the  two  tracings  as  for  plates,  very  little  work  is 
required,  a  few  bold  outlines  of  the  bon}^  landmarks  and  the 
foreign  body  accurately  drawn  will  suffice,  and  it  is  surprising, 
with  a  little  practice,  how  easy  they  are  to  produce  and  what 
useful  and  accurate  information  can  be  obtained.  (Illus- 
tration 8,  fig.  5.) 

Many  still  prefer  the  old  method  of  plates  at  right  angles, 
but  it  is  fast  being  discarded,  owing  to  the  ambiguity  involved 
when  the  foreign  body  is  not  in  the  same  plane  of  projection 
on  the  two  plates.  To  get  satisfactor}^  results  by  this  method 
the  normal  ray  should  be  centered  through  the  foreign  body 
in  both  directions,  when  the  information  given  is  reliable, 
although  insufficient  if  the  foreign  body  is  not  near  some 
anatomical  landmark,  shown  on  the  plate. 

Reference  to  Illustration  9  will  show  a  simple  antero- 
posterior and  lateral  tube  carrier  (designed  by  the  author)  that 
insures  the  same  projection.     It  is  extremely  useful. 

Observations  on  Foreign  Bodies. 

In  making  the  first  observations  on  foreign  bodies,  much 
expense  and  time  can  be  saved  by  having  a  number  of  sheets 
of  celluloid  cut  to  a  size  which  will  drop  into  the  frame  of 
the  fluorescent  screen.  Upon  these  celluloid  sheets  the 
position  of  foreign  bodies  may  be  traced  with  a  grease  (or 
glass)  pencil.  These  celluloid  tracings  ma}^  afterwards  be 
retraced  on  to  paper.  In  this  way  a  great  economy  of  plates 
may  be  effected,  and,  in  most  cases,  an  equal  amount  of 
information  obtained. 

Tracings  whth  the  Cryptoscope. 

These  can  easily  be  made  by  placing  the  sheet  of  paper  on 
a  thin  flat  board  and  using  a  pencil,  all  but  the  point  of  which 
is  enclosed  in  a  metal  holder;  by  approaching  the  cryptoscope 
as  close  as  possible  to  the  patient  the  enlargement  of  the  image 
is  reduced  to  a  minimum,  while  care  in  preserving  its  hori- 
zontal position  secures  a  projection  free  from  distortion. 
(Illustration  10.) 

Care  should  be  taken  to  work  with  a  small  diaphragm,  and 


X-Ray  Observations  for  Foreign  Bodies         17 

the  hands  should  never  be  allowed  to  come  into  the  fluorescent 
area  ;  good  gloves  and  full  protection  are  imperative,  and 
should  be  practised  only  when  the  exigencies  of  the  service 
demand  it. 


Illustration  10. 
Making  tracings  with  the  cryptoscope.     For  the  clearness  of  the  illus- 
tration the  cryptoscope  is  not  brought  near  the  tracing. 

The  Use  of  Bromide  Paper. 
The  economy  offered  by  bromide  paper  is  most  important 

c 


1 8         X-Ray  Observations  for  Foreign  Bodies 

in  war,  particularlyin  view  of  the  comparatively  large  quantity 
that  one  can  transport.  It  is  quite  possible  to  make  very  good 
radiographs  with  rapid  bromide  paper,  if  an  intensification 
screen  can  be  used.  Seventy-five  per  cent,  at  least  of  the 
graphs  of  foreign  bodies  can  be  taken  on  paper.  Bromide 
prints  made  in  this  way  are  particularly  useful,  when  only 
one  copy  is  required  to  accompany  a  patient  evacuated  to 
another  hospital.     (See  Appendix  II.) 

Pierced  Screen  Localisation.* 

This  method  is  very  useful,  exact,  and  of  extreme  simplicity. 
It  requires  a  small  fluorescent  screen,  pierced  with  a  hole  in 


Illustration  1 1. 

its  centre  (Illustration  ii),  intersected  by  a  cross  {d)  to  aid 
the  centering  of  the  foreign  body.  Through  this  perforation 
passes  a  thin  cord,  to  which  is  attached  a  small  lead  pellet 
This  cord  can  be  let  out  or  shortened  by  the  shaft  {m)  on 
which  it  is  wound,  h  is  a  travelling  bar  supporting  a  wire 
{w).  The  whole  is  held  horizontally  over  the  patient  by 
attachment  to  the  upright  (a),  and  is  hinged  as  indicated  in 
the  illustration. 

In  use  the  foreign  body  is  carefully  centered  under  the 
cross,  and  the  skin  is  marked  through  the  aperture  by  a  small 
stick  dipped  in  ink,  the  lead  pellet  is  now  removed  from  the 

*  Hirtz  (Gaiffe,  Paris),  Arch,  de  Med.,  1916. 


X-Ray  Observations  for  Foreign  Bodies         19 

small  receptacle  ;/,  and  sufficient  cord  released  to  allow  it  to 
just  touch  the  skin,  as  c,  i;  the  apparatus  may  now  be  turned 
up  (Fig.  B);  on  its  underside  is  fixed  a  measure,  against 
which  the  distance  from  screen  to  patient  is  read  off;  this  is 
noted,  and  the  board  is  again  lowered.  The  tube  is  now 
displaced  any  distance  at  right  angles  to  the  sliding  wire  w, 
which  is  then  adjusted  to  bisect  the  displaced  shadow  of  the 
foreign  body  (/).  The  patient's  limb  is  now  moved  aside, 
the  tube  operated  again,  and  the  lead  pellet  lowered  until  its 
shadow  is  bisected  by  the  wire  w,  as  was  the  shadow  of  the 
foreign  body ;  the  pellet  now  occupies  in  space  the  position 
recently  occupied  by  the  foreign  body  in  the  limb;  it  now 
simply  remains  to  lift  the  apparatus  again  on  its  hinges  and 
read  off  the  depth  of  the  foreign  body.  Subtracting  the 
distance  previously  measured  from  screen  to  patient  gives 
the  depth  of  the  foreign  body  below  the  mark  on  the  skin. 


GEOMETRICAL  LOCALISATIONS. 

Localisation  by  Triangulation. 

Originated  by  Sir  James  Mackenzie  Davidson,  this  method 
forms  the  basis  of  most  of  the  numerous  localising  appliances. 
It  is  very  simple,  and  in  the  hands  of  careful  workers  is  very 
exact.  When  used  in  detail  as  stipulated,  with  the  cross  thread 
localiser,  it  is  probably  the  only  method  applicable  to  tiny 
foreign  bodies  that  cannot  be  seen  on  the  screen,  or  are  in 
inaccessible  situations,  such  as  those  embedded  in  the  eye. 

Briefly  stated,  the  process  is  as  follows  (Illustration  12, 
Fig.  i).  Centre  the  tube  carefully  under  the  foreign  body 
with  the  diaphragm  well  closed  down,  and  mark  the  position 
of  the  shadow  on  the  screen  (if  it  is  large,  mark  one  corner). 
Now  mark  on  the  patient's  skin  a  dot  corresponding  to  this 
shadow,  and  it  is  obvious  that  the  foreign  body  is  situated 
vertically  below  this  mark,  and  an  incision  carried  sufficiently 
•deep  must  reach  the  foreign  body.  To  find  at  what  depth,  the 
diaphragm  should  be  opened  wider  and  the  tube  displaced  a 
tnown  distance  (say  10  cm.),  and  the  shadow  of  the  foreign 


20         X-Ray  Observations  for  Foreign  Bodies 

body  will  be  displaced  in  the  opposite  direction;  now  mark^ 
in  its  new  position,  the  identical  corner  of  the  foreign  body 
previously  marked.  With  a  pair  of  dividers,  carefully  measure 
this  distance  {bd),  and  write  it  down,  with  the  distance  {ac) 
that  the  tube  was  displaced.  The  only  further  measurement 
required   is   the   distance   from   screen   to   anticathode  {ab). 


Illustration  12. 


With  these  factors  known,  the  depth  of  the  foreign  body 
below  the  screen  is  found  by  multiplying  ab  by  bd,  and 
dividing  by  the  sum  of  ac  and  bd.  From  the  results  should 
be  subtracted  any  space  between  the  patient's  skin  and  the 
screen.      The    linear  path    of   the    rays    can    be    constructed 


X-Ray  Observations  for  Foreign  Bodies         21 

geometrically  on  paper  if  preferred,  using  a  hard  pencil  with  a 
sharp  point,  so  that  the  lines  may  be  as  fine  as  possible  and 
not  obscure  the  intersection.  Many  forms  of  mechanical 
apparatus,  such  as  that  shown  in  Illustration  13,  have  been 
constructed  to  do  away  with  the  necessity  of  calculations  and 
drawings,  and  other  sliding  rules  have  been  devised  to    give 


Illustration  13. 

the  depth,  in  reading  on  a  scale,  for  a  definite  tube  and  screen 
distance  and  tube  displacement. 

When  working  by  this  principle  it  is  as  well  to  work  to 
definite  distances,  such  as  50  cm.  from  the  tube  to  screen  and 
10  cm.  tube  displacement.  It  leads  to  accuracy,  and  me- 
chanical attachments  can  be  fitted  to  the  table  to  enable  the 
tube  displacement  to  be  made  in  the  dark. 


22         X-Ray  Observations  for  Foreign  Bodies 

When  desirable,  stereoscopic  plates  can  be  taken,  and  a 
localisation  made  at  the  same  time  by  replacing  the  screen  by 
plates  in  contact  with  the  patient,  the  only  difference  in  technique 
being  that  the  tube  is  displaced  3  cm.  to  the  left  of  the  central 
position  for  the  first  exposure,  and  3  cm.  to  the  right  of  the 
central  position  for  the  second  (see  Illustration  12,  Fig.  2), 
In  this  manner  the  surgeon  can  avail  himself  of  the  anatomical 
localisation  given  by  the  stereoscopic  plates  at  the  time  of 
operation. 

Tiny  Fragments. 
Fragments  too  small  to  see  on  the  screen,  which  yet  must 
be  removed,  are  best  located  by  the  complete  Mackenzie 
Davidson  technique.*  The  principle  is  as  previously  described,, 
but  as  the  foreign  body  cannot  be  centered,  means  must  be 
resorted  to  to  localise  it  wherever  it  may  fall  upon  the  plate.  To 
accomplish  this,  the  plate  must  first  be  tied  up  with  wire  as 
one  w^uld  tie  up  a  parcel,  with  the  cross  wires  intersecting  at 
the  centre  of  the  plate,  or  a  frame  or  drum,  with  two  wires 
affixed  crossing  at  right  angles,  may  be  devised  on  which  to 
place  the  plate.  If  an  under-table  tube  is  to  be  used,  means 
must  be  provided  to  centre  the  anticathode  immediately  under 
the  intersection  of  the  wires ;  this  can  be  accomplished  by 
adjusting  a  plumb-bob  to  overhang  the  centre  of  the  anti- 
cathode  b}^  an  arm  and  scaffold  that  travels  with  the  tube,  or 
the  cross  wires  may  be  placed  upon  the  surface  of  the  body 
and  the  tube  centered  by  placing  the  screen  on  top.  Which- 
ever way  it  is  accomplished,  the  skin  must  be  marked  with  the 
same  cross  lines,  and  a  small  coin  or  metallic  marker  put  in 
one  quadrant  and  the  same  marked  on  the  skin  for  identifica- 
tion later.  The  wires  should  be  placed  precisel}^,  so  that  one 
crosses  the  long  axis  of  the  body  horizontally  and  the  other 
verticall}^,  and  the  tube  displacement  should  be  made  across 
the  body.  Two  plates  are  now  taken,  the  first  with  a  displace- 
ment of  the  tube  3  cm.  to  the  left  and  the  second  3  cm.  to  the 
right  of  the  centre,  or  one  plate  can  be  used  with  the  double 
exposure  on  the  same  plate.  When  developed,  the  shadow  of 
*  "  Localisation  by  X-ray  and  Stereoscopy  "  (H.  K.  Lewis  and  Co.,Ltd.,London). 


X-Ray  Observations  for  Foreign  Bodies         23 

the  foreign  body  will  be  found  to  have  changed  its  position 
relative  to  the  cross  wires  on  the  two  plates  taken,  or  two 
shadows  will  be  found  on  the  one  plate.  When  dry,  take  a 
piece  of  transparent  paper  and  place  it  on  the  plate,  accurately 
mark  in  the  cross  lines,  the  impression  of  the  foreign  body, 


Illustration  14. 

the  indication  of  the  marked  quadrant,  and  the  second  shadow 
of  the  foreign  body  if  one  plate  was  used.  If  not,  place  the 
tracing  on  the  second  plate  with  the  lines  in  register,  and  add 
the  second  shadow  from  that  plate. 


24         X-Ray  Observations  for  Foreign  Bodies 

Armed  with  this  tracing,  go  to  the  cross  thread  apparatus 
and  place  the  tracing  in  register  with  the  cross  on  the  table 
of  the  apparatus  (Illustration  14) ;  adjust  the  height  of  the  arm 
that  carries  the  threads  and  indicates  the  two  positions  of  the 
anticathode.  Adjust  this  exactly  to  the  height  corresponding 
to  the  distance  from  anticathode  to  plate.  From  the  notch 
to  the  left  carry  the  thread  to  a  chosen  point  of  the  foreign 
body  traced  on  the  paper  to  the  right,  and  the  right  hand  thread 
to  the  same  point  on  the  left.  Where  the  lines  cross  is  the 
position  of  the  foreign  body.  Now  take  the  indicator  pro- 
vided with  the  apparatus  and  adjust  it  to  the  height  of  the  cross 
in  the  threads,  and  read  off  the  depth  of  the  foreign  body  on  the 
vertical  scale.  Then  place  the  vertical  scale  on  the  cross  line 
of  the  table  that  forms  one  side  of  the  quadrant  in  which  the 
cross  threads  fall.  Measure  with  dividers,  at  .the  level  of  the 
cross  in  the  thread,  the  distance  of  this  cross  from  the  vertical 
scale.  Repeat  in  respect  to  the  second  line  of  the  quadrant. 
Now  draw  on  the  tracing,  at  the  distances  just  ascertained, 
two  lines  parallel  to  those  from  which  the  measurements  have 
been  made.  The  intersection  of  these  lines  gives  the  point 
vertically  below  which,  at  the  depth  ascertained,  the  foreign 
body  lies.  The  information  is  now  complete.  Now  go  to 
the  patient,  identify  the  quadrant,  and  mark  in  your  data. 

Additional  Procedure  Necessary  for  the  Eye. 

Before  taking  the  plates  for  eye  localisation  a  certain  pre- 
paration of  the  patient  is  necessary.  First,  a  few  drops  of 
novocaine  may  be  dropped  in  the  eye  to  allay  irritation,  if 
present.  Then  a  small  piece  of  fine  lead  fuse  wire  should  be 
taken,  bent  double  to  avoid  a  sharp  surface,  and  affixed  to  the 
cheek  so  that  the  folded  end  can  be  placed  in  contact  with  the 
lower  e57elid  vertically  below  the  cornea.  Notes  must  now  be 
made  of  the  exact  position  of  this  end,  its  distance  below  the 
centre  of  the  cornea  being  observed  from  the  frontal  position, 
and  its  distance  in  front  of  or  behind  the  centre  of  the  cornea 
obtained  from  lateral  observation.  These  measurements  should 
be  very  accurately  ascertained  with  dividers,  as  it  is  in  relation 
to  this  identification   point  that    localisation  calculations  are 


X-Ray  Observations  for  Foreign  Bodies         25 

made.  It  must  be  done  when  the  patient  is  in  the  position  in 
which  the  radiographs  are  to  be  taken,  with  the  visual  axis 
parallel  to  the  horizontal  wire. 

To  keep  the  gaze  steady,  while  the  plates  are  being 
taken,  a  bright  object  should  be  placed  at  a  distance  and 
exactly  in  front  of  the  patient,  at  which  he  should  look  during 
both  exposures.  Lateral  plates  are  taken,  the  cross  wires 
being  arranged  with  their  intersection  in  front  of  and  below 
the  eye,  so  that  the  foreign  body  shall  not  be  obscured  by  the 
wire.  The  tube  must,  of  course,  be  carefully  centered  to  the 
intersection  of  the  wires.  From  plates  so  taken  the  relation- 
ship of  the  foreign  body  to  the  point  of  the  lead  wire  can  be 
absolutely  determined,  and  the  relationship  of  the  lead  wu-e 
to  the  cornea  being  known,  the  position  of  the  foreign  body 
in  the  eye  can  be  definitely  stated.  The  use  of  a  model  eye 
of  a  definite  enlargement,  and  the  necessary  multiplication  of 
the  localisation  figures,  will  help  materially  to  decide  the 
anatomical  situation  of  the  foreign  bodv,  and  the  possibility 
of  its  removal. 

The  same  technique,  if  desirable,  is  practicable  ni  anatomical 
localisation  in  other  parts,  employing  any  metallic  indicator 
placed  on  the  skin,  or  choosing  a  body  landmark  in  the 
radiograph  sufficiently  distinct  to  be  easily  identified. 

General  observations  on  foreign  bodies  in  the  eye  can  be 
made  by  taking  a  small  lateral  plate,  wnth  two  exposures  on 
the  same  plate,  one  with  the  patient  looking  down,  the  other 
•looking  upwards.  If  the  foreign  body  is  in  the  eye  itself,  two 
shadows  will  be  shown,  unless  it  is  situated  in  the  axis  of 
rotation;  if  it  is  in  this  axis  there  will  be  no  duplication  of  the 
shadow.  Otherwise,  the  position  of  the  foreign  body  is 
•shown  by  the  movement  of  the  shadow.  If  the  movement  is 
backwards  and  downwards,  it  lies  in  the  posterior  superior 
•quadrant  ;  if  downwards  and  forwards,  in  the  posterior  in- 
ferior quadrant ;  if  upwards  and  forwards,  in  the  anterior 
inferior  quadrant ;  if  upwards  and  backwards,  in  the  anterior 
superior  quadrant.  An  antero-posterior  plate  taken  with  a 
small  fine  wire  cross,  with  its  intersection  central  to  the  cornea 
Avill  give  additional  information.     This  is  a  very  specialised 


26         X-Ray  Observations  for  Foreign  Bodies 

branch  of  the  work  needing  particular  care,  and  should  only 
be  undertaken  by  those  possessed  of  the  necessary  know- 
ledge and  experience. 

Dr.  Belot  and  Dr.  Fraudet  have  developed  the  above  method 
with  a  special  technique  that  gives  a  very  accurate  localisation 
and  necessitates  very  little  additional  apparatus.     Their  pro- 
cedure is  divided  into  two  sections — exploration  and  precise 
localisation. 

A  lateral  fluoroscopic  examination  is  made  first,  and  the 
whole  area  carefully  studied  with  a  very  small  diaphragm 
opening  ;  foreign  bodies  may  be  found  in  other  parts  of  the 
head  and  face,  and  by  rotation  of  the  head  it  is  easy  to  decide 
roughly  their  position.  This  examination  is  necessary  to 
prevent  confusion,  should  there  be  more  than  one  in  the 
region. 

The  head  is  now  placed  in  a  lateral  position  for  the  examina- 
tion of  the  eye  in  question.  With  the  screen  in  contact  with 
that  side  of  the  face,  the  tube  is  adjusted  so  that  the  normal 
ray  shall  pass  through  the  orbital  cavities;  this  position  is  easy 
to  identify  by  the  bright,  ahnost  oval  patch  appearing  just 
posterior  to  the  nasal  bones. 

If  a  foreign  body  is  found  here,  it  remains  to  determine 
whether  it  is  in  the  globe;  this  can  be  ascertained  by  telling  the 
patient  to  look  up  and  then  down.  The  movement  of  the 
foreign  body  may  then  be  interpreted;  if  it  moves  m  the  same 
direction  as  the  eye,  it  will  be  in  the  anterior  hemisphere,  and 
if  against  it,  in  the  posterior  hemisphere.  Further  differentia- 
tion will  be  necessary,  because  a  foreign  body  in  the  muscles 
producing  the  movements  of  the  eye  will  also  be  displaced; 
this  will  be  dealt  with  later.  Care  should  be  taken  to  exclude 
the  possibility  of  foreign  bodies  in  the  eyelids.  Should  the 
shadow  of  a  foreign  body  be  seen  very  anterior,  and  moving 
rapidly  on  the  patient's  opening  and  closing  the  eye,  this, 
location  may  be  suspected.  The  parts  may  be  individually 
immobilised  during  the  screen  examination;  from  such  pro- 
cedure a  diagnosis  can  be  formed.  Much  useful  additional 
and  corroborative  information  can  be  obtained  by  a  supple- 
mentary antero-posterior  examination.  - 


X-Rav  Observations  for  Foreign  Bodies         27 


For  the  exact  localisation  five  radiographs  are  required, 
three  lateral  and  two  antero-posterior. 

It  is  necessary  for  this  method  that  the  sight  be  preserved 
in  one  eye,  and  that  the  wounded  eye  shall  have  retained  its 
mobility.  It  may  then  be  assumed  (should  the  injured  eye 
not  have  retained  sufficient  sight)  that  the  two  eyes  will  make 
identical  movements.     The  eye  is  regarded  as  a  sphere  whose 


Illustration  15. 

Position  of  the  patient  on  the  table  with  the  rule  and  movable  lamp  to 

direct  the  gaze  of  the  patient.     Tunnel  under  which  to  slide  the  plate. 

ai.    The  angle  swept  by  the  eye  when  looking  up.    a2.    The  angle  swept 

by  the  eye  when  looking  down.     a. p.,  the  cross  wire  over  the  plate. 

movements  are  those  of  rotation  about  a  centre  which  remains- 
fixed;  a  foreign  body  in  the  eye  will  make  movements  definitely^ 
related  to  those  of  the  eyeball.  The  comparison  and  study^ 
of  successive  radios,  between  which  the  eye  has  been  rotated 
in  a  definite  sense, will  give  data  from  which  an  exact  localisa- 
tion can  be  made. 


28         X-Ray  Observations  for  Foreign  Bodies 

If  the  foreign  body  rotates  about  the  same  axis  and  through 
the  same  angle  as  the  eye,  it  is  certainly  in  the  eyeball,  or  in  a 
part  of  the  muscle.  If  the  displacement  is  not  a  rotation  about 
the  same  axis,  a  careful  study  will  show  if  it  is  in  the  soft  parts 
or  in  a  muscle,  and  ultimately  in  which  muscle  it  is  situated. 

For  the  production  of  the  lateral  radiographs,  it  is  desirable  to 
use  a  small  table  with  a  tunnel,  so  that  the  plates  can  be  easily 
changed  while  the  head  is  kept  immobilised;  quite  small  plates 
will  suffice,  say  9  by  12  cm.  Across  the  opening  under  which 
the  plate  slides  a  fine  wire  is  placed.     The  head  is  adjusted  on 


/n  /roni. 


/breijf/i  /body . 


Illustration  16. 
This  illustration  shows  the  relative  positions  of  the  eye  and  the  plate  in 
the  production  of  the  lateral  radiographs.     The  axes  are  also  shown. 
a.p.,  the  wire  over  the  plate.     Ao-Po,  the  corresponding  axis. 

the  tunnel  in  such  a  manner  that  the  metal  wire  is  parallel  to 
an  imaginary  line  passing  through  the  centre  of  the  cornea  and 
back  through  the  central  axis  of  the  eye,  while  the  patient 
gazes  to  the  horizon,  and  that  the  shadow  of  the  wire  on  the 
plates  coincides  with  this  line;  thus  the  horizontal  equator  of 
the  eye  is  materialised.     (Illustration  15,) 

The  tube  should  be  centered  above  at  a  sufficient  distance  to 
ensure   that   the  resulting  radiograph    of   the   globe  may  be 


X-Rav  Observations  for  Foreign  Bodies 


29 


considered  an  orthogonal  projection.  Froma  platesoobtained, 
measurements  may  be  considered  actual  (for  the  lateraB 
radiograph,  80  cm.  from  a,nticathode  to  plate  gives  a  maximum 
error  of  i  mm.;  for  the  antero-posterior,  65  cm.  gives  the  same 
error).  The  normal  ray  should  pass  through  the  central  axis 
of  the  eye,  and  at  right  angles  to  the  plate. 

With  the  patient,  tube,  and  plate  so  arranged,  three  radio- 
graphs are  now  made  with  the  head  immobilised;  in  the  first 
plate  (to  be  marked  "0")  the  patient's  gaze  is  directed  to  the 
horizon,  in  the  second  it  is  directed  upwards,  and  in  the  third 
downwards,  and  the  plates  are  marked  accordingly. 


Illustration  17. 
The  relative  positions  of  the  eye  and  the  plate  are  here  shown  for  the 

production  of  the  antero-posterior  radiographs. 
ie  and  bb    The  cross  wires  in  front  of  the  eye  and  their  corresponding 
axes  are  shown. 

For  the  antero-posterior  radiographs  two  fine  cross  wires 
are  required,  and  while  the  patient  gazes  to  the  horizon  (or 
in  this  case  vertically  up  to  the  ceiling),  the  frame  carrying, 
the  cross  wires  is  adjusted  so  that  the  intersection  shall  be 
vertically  over  the  centre  of  the  cornea,  and  the  wires  coincide 
with  the  horizontal  and  vertical  equators  of  the  eye ;  on  these 
the  plate  is  placed.  The  tube  must  now  be  centered  so  that 
the  normal  ray  shall  pass  through  the  intersection  of  the 
cross  wires.  With  the  patient  so  disposed,  and  tube  and 
plate  arranged,  the  first  plate  is  exposed,  and  for  the  second 
exposure  the  patient  is  directed  to  gaze  to  the  side  opposite 
to  that  of  the  injured  eye  (adduction).     Five  plates  have  now 


30         X-Ray  Observations  for  Foreign  Bodies 

been  taken,  and  from  the  study  of  these  the  diagnosis  will  be 
made.     (Illustrations  i6,  17.) 

The  first  step  towards  localisation  is  to  make  tracings  from 
the  radiographs — from  each  set  one  composite  tracing  is 
made.  From  plate  "  0  "  the  outHnes  of  the  bony  skeleton  of 
the  orbit  and  of  the  metal  wire  are  drawn  on  transparent  paper. 
The  foreign  body  is  also  traced;  this  should  be  done  accu- 
rately, with  attention  to  any  orientation  it  may  possess;  then 
carefully  superimposing  the  tracings  on  the  plates  marked  "  up  " 
and  "  down,"  the  other  shadows  of  the  foreign  body  are  added. 
The  same  procedure  is  followed  in  the  production  of  the 
antero-posterior  tracing.  These  tracings  may  be  called 
'•  lateral"  and  "frontal."     (Illustrations  18,  19.) 


Illustration  18. 
Lateral  Tracing. 


Illustration  19. 
Frontal  Tracing. 


It  is  possible  that  the  shadows  of  the  foreign  body  may 
completely  overlie;  they  may  overlie  in  one  tracing  and  be 
neatly  separated  in  the  other;  or  they  may  be  separated  in  both. 

A  foreign  body  that  has  not  moved  in  either  is  (ci)  not  in 
the  eye  at  all,  or  {b)  in  the  centre  of  the  eye;  this  latter  possi- 
bility is  important  and  must  never  be  overlooked;  it  may  mean 
a  tiny  foreign  body  located  in  the  vitreous  humour,  or  adhering 
to  the  posterior  surface  of  the  crystalline  lens.  If  the  foreign 
body  is  in  the  centre  of  the  globe,  its  position  in  the  lateral 
tracing  will  be  slightly  anterior  to  the  shadow  of  the  malar 
border  of  the  orbit,  and  near  also  to  the  shadow  of  the  wire 
that  materialises  the  horizontal  axis  of  the  eye ;   and   on  the 


X-Ray  Observations  for  Foreign  Bodies         31 

frontal  tracing  it  will  coincide,  or  nearly  so,  with  the  centre  of 
the  cross  wires.  This  question  will  only  arise  when  the  foreign 
body  is  very  tiny  and  spherical  in  shape,  otherwise  it  will  be 
possible  to  follow  its  orientations  in  the  changes  of  position. 

Where  the  foreign  body  is  on  one  of  the  axes  of  rotation, 
but  not  central,  the  shadow  will  have  moved  in  one  of  the  two 
tracings.     (Illustration  20.) 


Fig.  I. 


i.         \ 


Fig.  2. 


Illustration  20. 

Foreign  Body  situated  on  the  Horizontal  Axis  of  the  Eye. 

Fig.  I.  A  horizontal  section  cut  at  the  level  of  the  centre  of  the  eye 

when  the  eye  looks  to  the  horizon. 
Fig.  2.  Frontal  tracing  from  two  radiographs,  between  which  the  eye 
has  moved  in  adduction  ;  the  tracing  shows  the  movement  of  the  foreign 

body  in  such  a  case. 
Foreign  body  R  in  the  temporal  hemisphere  during  adduction  moves  for- 
ward from  the  position  Ro  to  the  position  Rl,  that  is  to  say  it  is  dis- 
placed towards  the  centre. 
Foreign  body  S,  in  the  nasal  hemisphere,  is  carried  back  towards  the 

centre. 

In  the  case  in  which  the  foreign  body  has  moved  and  pro- 
duced the  three  successive  shadows  on  the  lateral  tracing,  the 
process  is  as  follows.  Two  fine  lines  are  drawn  connecting  the 
three  shadows  (using  the  same  point  of  oriental  ion  of  the 
foreign  body),  and  from  the  centres  of  these  lines  two  perpen- 
diculars are  drawn;  their  intersection  forms  the  centre  of  a 
circte  passing  through  the  three  positions  of  the  foreign  body 


32         X-Ray  Observations  for  Foreign  Bodies 

(see  Illustration  21).  In  this  manner  the  centre  of  the  globe 
is  materialised.  If  this  point  falls  just  anterior  to  the  malar 
border  of  the  orbit,  the  foreign  body  is  in  the  globe,  and  its 
position  can  be  given  in  two  directions,  and  the  third  obtained 
from  the  frontal  tracing.  If  the  intersection  falls  remote  from 
the  malar  border,  and  from  the  horizontal  plane  projection^ 
the  foreign  body  is  not  in  the  globe  but  in  one  of  the  muscles, 
(See  Illustrations  22-25.) 


Illustration  21. 

The  geometrical  construction  on  the  lateral  tracing  foreign  body  in  the 

eye. 
Inferior  posterior  quarter. 

To  ascertain  if  the  movement  of  the  foreign  body  corre- 
sponds to  the  rotation  of  the  eye,  a  long  ruler,  fitted  with  a 
movable  electric  lamp,  is  placed  at  a  known  distance  from  the 
patient  and  used  to  direct  his  gaze,  and  the  displacements 
above  and  below  the  central  or  horizontal  position  are  recorded. 
With  this  information  (using  cm.  to  represent  metres)  the  angle 
the  eve  has  turned  through  can  be  reconstructed  on  the  lateral 


X-Ray  Observations  for  Foreign  Bodies         33 

tracing,  showing  definitely  whether  the  foreign  body  has  turned 
ithrough  the  same  angle.      (Illustrations  15,  26-27-31.) 

In   those  tracings  which   show  that  the  foreign  body  has 
smoved,  and  yet  the  centre  of  the  circle  on  which  the  shadows 


Illustration  22. 
Lateral  Tracing. 
Foreign  body  in  the  superior  rectus. 
Fig.  I.  The  elevation  of  the  eye 
produced  by  the  contraction  of  the 
superior  rectus  muscle  causes  the 
foreign  body  to  be  pulled  nearer  to 
the  fixed  insertion  of  the  muscle 
(Shadow  I). 

When  the  eye  is  lowered  the  reverse 
takes  place.  The  superior  rectus  is 
lengthened,  displacing  the  shadow  of 
the  foreign  body  to  the  opposite 
side  (shadow  2)  of  the  zero  position 
■(shadow  0)  which  is  the  shadow 
formed  when  the  patient  gazed  to 
the  horizon. 

The  Frontal  Tracing. 

Fig.  2.    The  movement  of  adduction 

^has  hardly  moved  the  foreign  body; 

the  two  shadows  overlie. 


Illustration  23. 
Foreign   Body    in   the    inferior 
rectus. 
Lateral  Tracing. 
Fig.  I.  In  this  case  thelowering 
of  the  eye  produced  by  the  con- 
traction of  the  inferior  rectus 
draws  the  foreign  body  nearer 
to  its  fixed  insertion  (shadow  2), 
while  the  elevation  of  the  eye 
by     the     contraction     of     the 
superior  rectus    lengthens    the 
inferior  and  again  displaces  the 
foreign    body    to   the    opposite 
side  (shadow  I)  of  zero. 

Frontal  Tracing. 
Fig.  2.  No  movement  is  shown 
in    the  frontal  radiograph;   the 

shadows  overlie. 


34-        X-Ray  Observations  for  Foreign  Bodies 

lie  does  not  occur  at  the  point  indicated  as  the  centre  of  the 
globe,  a  little  study  will  reveal  the  actual  position  of  the  foreign 
body  ;  bearing  in  mind  the  muscles  that  produced  the  move- 
ments of  the  eye  recorded  on  the  plates,  interpretation  i& 
comparatively  simple.     (Illustrations  22-25.) 

Position  of  Patient. 

In  all  methods  of  localisation,  with  one  mark  on  the  skin 
below  which  at  a  measured  distance  in  the  vertical  line  a 
foreign  body  is   situated,  all  the  general  information  of  the. 


Illustration  24. 
Lateral  tracing    with   the  geometrical  construction  showing  a  foreign- 
body  moving  with  the  eye  but  not  in  the  globe.     The  centre  of  rotation 
K  is  shown  to  be  some  distance  away  from  the  position  known  to  be  the 
centre  of  the  eye. 

previous  examination  should  be  studied.  The  patient  should,, 
if  possible,  be  placed  for  the  more  exact  localisation  in  sucb 
a  position  that,  when  he  is  operated  upon,  a  vertical  incision 
can  be  made  through  the  localisation  mark.  If  no  satisfactory 
previous  information  is  at  hand,  rough  observations  should' 
be  made,  for  it  will  frequently  occur  that  the  foreign  body  i& 
not  nearest  to  the  surface  at  the  point  indicated,  or  important 
structures  may  intervene  making  it  undesirable  to  operate 
through  this  point.  It  is,  therefore,  necessary  to  consider  the 
position  of  the  foreign  body,  and  the  best  means  of  approach,, 
and  localise  it  with  the  patient  so  placed.  It  matters  little  if 
the  incision  has  to  be  carried  a  little  deeper  along  the  localisa- 


X-Ray  Observations  for  Foreign  Bodies         35 

tion  line,  for  one  is  fairly  sure  to  strike  the  foreign  body. 
But  careful  judgment  is  necessary  to  enter  laterally  for  a 
foreign  body  localised  in  this  manner,  and  the  operation  is 
often  unsuccessful,  the  slightest  deviation  resulting  in  failure. 


Fig.  I. 


Fig.  2. 


Illustration  25. 

Foreign  Bodies  in  the  Internal  and  External  Rectus. 

Fig.  I.     Horizontal  cross  section  at  the  level  of  the  internal  and  external 

rectus..  A. P.  shows  the  antero-posterior  axis. 
Fig.  2.     Frontal  tracing  (composite)  showing  the  shadows  of  the  foreign 

body  produced  by  the  movements  of  the  eye. 
Ro  foreign  body  in  the  external  rectus.     Plate  taken  with  the  patient 
gazing  to  the  horizon  gives  the  shadow  0,  formed  by  the  foreign  body 
when  at  Ro.     On  adducting  the  eye  the  external  rectus  is  lengthened  and 
the  foreign  body  moves  to  Rl,  placing  the  shadow  on  the  radiograph  at 

I,  that  is  to  say  outward  displacement. 
So  foreign  body  in  the  internal  rectus.  Plate  taken  with  the  patient 
gazing  to  the  horizon  gives  the  shadow  O'  formed  by  the  foreign  body 
when  at  So.  The  second  radiograph  taken  with  the  eye  in  adduction 
produced  by  the  contraction  of  the  internal  rectus  draws  the  foreign 
body  nearer  to  the  fixed  insertion  of  the  muscle  Si,  giving  the  shadow  l'. 

AnatoxMical  Localisation. 
While   geometrical    localisations  are  absolutely    necessary^ 
much   more  information  is  desirable  to  ensure  the  successful 


36         X-Ray  Observations  for  Foreign  Bodies 

removal  of  foreign  bodies.  It  is  never  easy,  in  fact,  rarely 
possible,  to  state  the  exact  position  of  a  projectile  from  flat 
plates.  Antero-posterior  and  lateral  radiographs  at  right  angle 
planes  and  of  the  same  projection  are  useful,  and,  at  times, 
desirable,  but  they  are  a  poor  substitute  for  stereoscopic  plates. 
From  the  latter  the  most  valuable  information  can  be 
obtained. 

In  the  limbs,  rotation  and  observations  from  several  aspects 
may  demonstrate  whether  the  foreign  body  is  in  soft  tissues 
or  embedded  in  bone;  but  at  an  articulation,  tarsus,  carpus, 
shoulder,  or  vertebrae,  every  available  device,  manipulation, 
and  the  use  of  discriminating  judgment  will  often  be  necessary 


Illustration'26. 
Reproduction  of  the  angle  of 
rotation  of  the  eye  on  a  milli- 
metre to  the  centimetre  scale. 


Illustration  27. 

Geometrical  construction  of  the  angle 

of  rotation  of  the  eye. 


in  order  to  come  to  a  definite  conclusion.  Besides  turning 
the  limb  or  body,  use  should  be  made  of  the  oblique  rays,  by 
long  displacement  of  the  tube,  in  the  hope  of  being  able  to 
throw  the  shadow  free  from  bony  structures. 

It  is  even  more  difficult  to  decide  the  location  of  a  foreign 
body  in  the  thorax,  abdomen,  or  pelvis.  A  projectile  in  the 
lung  may  move  with  respiration  or  not,  depending  upon  its 
location  ;  at  the  root  there  would  be  little  if  any  movement, 
while  at  the  base  the  excursion  may  be  considerable.  How- 
ever, it  must  not  be  forgotten  that  a  foreign  body  may  be  pre- 
vented from  moving  and  yet  be  in  a  lung  restricted  by  adhesions. 


X-Ray  Observations  for  Foreign  Bodies         37 

On  the  other  hand,  the  moving  shadow  of  the  ribs  may 
impart  to  the  foreign  body  an  apparent  movement  it  does  not 
possess.  Further,  the  presence  of  air  or  fluid  in  the  pleural 
cavity  will  complicate  matters,  and  with  a  projectile  fairly 
superficial  in  the  lung  it  may  be  impossible  to  make  a  definite 
statement  in  a  few  cases.  Frequently,  an  abscess  forms  about 
the  foreign  body,  and   later  a  cavity  containing  air,  fluid,  or 


Illustration  28. 
Dotted  line  of  the  diaphragm,  normal  respiration— dotted  foreign  body- 
in  the  liver  shadow  :  dark  line  of  diaphragm,  forced  inspiration — dark 
foreign  body  projected  above  liver  region. 

both,  and  the  projectile  may  be  shown  to  be  free  in  some 
cases  by  changing  the  position  of  the  patient  and  allowing 
some  time  to  elapse  between  observations. 

Not  infrequently,  a   projectile  may  be  near  or  attached  to  a 
large  vessel,  and  a    "  kick  "  may  be  observed  imparted  by  the 


38         X-Ray  Observations  for  Foreign  Bodies 

pulsation,  or  such  a  movement  may  be  communicated  by  the 
heart;  in  this  latter  case,  the  excursion  of  the  foreign  body 
will  be  greater,  and  may  be  seen  to  occur  in  the  mediastinum 
and  over  a  large  area  of  the  left  lung,  but  may  be  somewfiat 
modified  if  the  lung  is  partially  collapsed  or  consolidated  in 
the  vicinity. 


Illustration  29. 

The  circles  indicate  the  positions  of  the  X-ray  tube  with  the  corresponding 

projections  on  the  screen  when  examining  the  region  of  the  diaphragm. 

These  cases  should  all  be  submitted  to  thorough  general 
observation,  and  all  conditions  noted  and  recorded  with  the 
localisation.  Some  help  can  be  obtained  by  applying  a  small 
metal  ring  to  the  chest  wall  and  observing  the  behaviour  of  the 


X-Ray  Observations  for  Foreign  Bodies         39 

foreign  body  in  relation  to  this  shadow.  If  the  foreign  body 
rises  with  inspiration  and  remains  fixed  in  its  relation  to  the 
ribs,  it  is  most  probably  in  or  attached  to  the  chest  wall. 

Attention  to  every  detail  is  imperative,  and  statements  should 
be  made  with  the  greatest  caution,  for  upon  these  findings 
important  and  responsible  decisions  are  to  be  made. 

To  decide  the  location  of  a  projectile  in  the  region  of 
the  diaphragm  is  particularly  difficult.  Forced  inspiration  will 
often  show  a  foreign  body  to  be  above  the  diaphragm,  when  its 
shadow  was  projected  well  within  the  liver  area  with  normal 
respiration  (Illustration  28).  The  patient  should  be  observed 
from  every  position.  To  search  the  posterior  inferior  portion  of 
the  chest  the  tube  should  be  lowered  posterior  to  the  level  of  the 
fourth  lumbar  vertebra,  when,  by  the  oblique  ray,  the  shadow 
may  be  thrown  well  above  the  diaphragm,  settling  all  doubt 
as  to  its  position.  If  this  is  not  successful  the  position 
should  be  reversed.     (Illustration  29.) 

It  is  often  impossible  to  give  definitely  the  position  of 
foreign  bodies  in  the  abdomen.  They  may  move  freely  from 
time  to  time.  For  this  reason  observation  on  fresh  cases 
should  be  made  within  a  few  hours  of  operation.  Further- 
more, it  is  not  an  unusual  occurrence  for  a  foreign  body  to  be 
passed  by  the  rectum,  and  should  this  occur  a  patient  might 
be  submitted  to  a  needless  operation.  In  cases  where  special 
difficulty  exists,  or  an  anatomical  localisation  is  uncertain, 
preparation  should  be  made  at  the  time  of  operation  for 
intermittent  control  by  the  fluorescent  screen. 

Stereoscopic    Localisation.* 

Undoubtedly,  good  stereoscopic  plates  give  more  informa- 
tion than  antero-posterior  and  lateral  plates,  and  in  difficult 
cases  they  should  always  be  taken,  particularly  if  one  of  the 
stereoscopes  for  viewing  and  measuring  the  depth  of  the 
foreign  body  by  a  mechanical  attachment  is  at  hand,  such  as 

*  "  La  Radiostereoscopie  en  Chirurgie  de  Guerre,"  Juiiv.  dc  Raaiol.  cf  cfEL, 
March,  1916. 

"La Localisation  Anatomique  des  Projectilespar  la  Radiographic  Stereo- 
scopique."     Loccit. 


40         X-Ray  Observations  for  Foreign  Bodies 

the  Maze  Radiostereometer*  (Illustration  30),  or  the  stereo- 
thesmetre  of  Paris  Richard.  To  this  apparatus  is  fixed  la. 
small  handle  that  controls  the  passage  of  a  measure,  and 
indicates  on  a  dial  the  depth  of  the  foreign  body.  The- 
relation  of  the  foreign  body  can  also   be  determined  to   any 


Illustration  30. 
Stereoscope  for  measuring  the  depth  of  foreign  bodies.    C — X-ray  plate,. 
j^ — Movable  register,  G- -Mirror  bisector.     On  the  front  is  the  dial  that 
indicates  in  millimetres  the  depth  of  the  foreign  body. 

other  structure  shown  on  the  plate.  The  calculations  in  this- 
case  are  based  on  a  distance  from  tube  to  plate  of  50  cm. 
The  first  exposure  is  made  from  the  central  position,  and  the 
second  with  a  lateral  displacement  of  4  cm,,  which  measure- 

*  Arch.  d'ElcdricUc  Med.,  Oct.,  1917. 


X-Ray  Observations  for  Foreign  Bodies         41 

ment  must  be  rigorously  adhered  to.  The  most  portable  and 
convenient  form  of  stereoscope  is  the  Binocular  or  Pierre 
form,  or  the  Hirtz  Mirror  bisector  type. 

A  simple  appliance  on  this  principle,  devised  by  the 
author,*  makes  it  possible  to  exercise  considerable  economy 
in  stereo-radiography  of  the  limbs,  and  no  complicatedapparatus- 
is  required  for  viewing.     A  small  metallic  badge  may  be  used 


Illustration  31. 
Stereoscopic  realisation  with  a  simple  mirror. 

to  mark  the  sinus  or   wound,  and  a  letter  (the  same  one  as 

that  used    for    the  purpose    of    marking  "  left "    or  "right") 

should  be   placed  upon  the  anterior  surface  of  the  liinb.     A 

plate  is  now  taken,  half  of  which  is  placed  under  the  limb'  in 

the  usual  position,  with  the  film  towards  the  tube,  the  other 

*  "Stereoscopic   Radiography  of  the  Limbs,"  Arcli.  Radiol.'aiid  Electro- 
therapy, June,  1917;  B.M.J.,  Sept.  29th,  1917. 


42         X-Ray  Observations  for  Foreign  Bodies 

half  of  the  plate  being  covered  by  sheet  lead.  The  tube  is 
-centered  over  the  limb,  and  afterwards  displaced  3  cm.  laterally. 
After  the  first  exposure  the  plate  is  carefully  withdrawn 
without  disturbing  the  limb,  and  the  unexposed  half  of  the 
plate  inserted,  this  time  with  the  glass  side  towards  the  tube. 
The  second  exposure  is  then  made  after  the  tube  has  been 
again  displaced  3  cm.  on  the  opposite  side  of  the  centre.  It 
will  be  found  that  the  best  stereoscopic  results  will  be  obtained 
by  increasing  the  displacement  for  a  thin  limb,  like  forearm 
or  hand,  to  as  much  as  4  cm.  on  either  side  of  the  centre  ; 
while  for  the  thigh  the  displacement  should  be  diminished. 
The  height  of  the  tube  has  also  some  influence  upon  the 
stereoscopic  effect  ;  the  closer  the  tube  is  to  the  plate,  the 
less  displacement  is  required.  To  view  these  plates  when  so 
taken,  all  that  is  required  is  two  mirrors,  some  20  cm.  by 
25  cm.  in  size,  placed  back  to  back,  and  bound  for  convenience 
with  a  piece  of  adhesive  tape  (Illustration  31).  The  whole  of 
the  plate  must  be  equally  illuminated.  The  mirror  should  be 
placed  in  the  centre  of  the  two  pictures,  and  the  observer 
should  close  an  eye  until  he  sees  one  picture  clearly  reflected. 
When  both  eyes  are  open  a  stereoscopic  projection  is  obtained. 
The  position  of  the  sinus  (marked  by  the  metal  disc)  becomes 
evident  ;  and  sequestra  or  foreign  bodies,  which  might  appear 
as  one  in  an  ordinary  radiograph,  will  now  stand  out  in 
relief,  and  can  be  enumejated,  and  accounted  for  at  the 
subsequent  operation.      (Plate   i.) 

Should  the  letter  placed  anteriorly  appear  on  the  side  oppo- 
site to  the  observer,  he  is  viewing  the  posterior  aspect ;  to 
obtain  the  anterior  aspect,  he  must  incline  the  head  to  the 
opposite  side  and  use  the  other  mirror. 

Cross  Section  Localisation  by  Three  Intersecting 

Lines.* 

The  old  method  of  localisation  by  two  intersecting  lines  was 

not  exact,  and  the  method  and  technique  to  be  described  has 

been    developed    and    perfected    by    the    author.       It    is    un- 

"  Belot  et  Fraudet,  Jour,  dc  Radiol,  et  d'Ekcli  other.,  Jan.,  1916. 
J.  M.  Flint,  Ann.  Surg.,  Aug.,  1916. 
H.  C.  Gage,  Aicli.  Radiol,  and  Elccirollicr.,  June,  1917. 


A  typical  stereo-radiograph  which  if  viewed  with  a  mirror  will  immediately 
illustrate  the  advantages  of  the  method  described.     (The  sinus  in  this  case  is 

marked  with  a  pin.) 
Plate  I. 


44 


X-Kav  Observations  for  Foreign   Bodies 


doubtedly  the  one  of  choice  where  the  foreign  body  can  be- 
seen  on  the  screen.  It  is  independent,  as  will  be  seen,  of  any 
mathematical  calculations,  it  is  accurate,  and  the  results  are 
self-proving,  for  the  chart,  when  complete,  discloses  at  once  if 
the  observations  have  been  made  correctly  or  not.  The  method 
in   itself  comorises   geometrical  and   anatomical    localisation 


3. 0.  Q 


Illustration  32, 
Localising  appliances. 

combined  with  mechanical  guidance.  The  appliances  neces- 
sary are  very  simple,  and  can,  should  the  situation  demand 
it,  be  home  made.     (Illustration  32.) 

Two  pairs  of  compasses  are  shaped  as  illustrated  in  Figs. 
I  and  2.     Two  sizes  are  necessary,  as  it  is  desirable  that  the 


X-Ray  Observations  for  Foreign  Bodies         45 

rings  shall  be  parallel  when  in  use;  a  large  pair  (for  the  body) 
about  35  cm.  long,  a  second  pair  (for  the  limbs)  about  12' 5 
cm.  The  rings  in  each  case  can  be  made  to  enclose  smaller 
rings  to  facilitate  the  centering  of  a  tiny  foreign  body  (Figs,  i 
:and  2,  b,  c,  and  d).  The  body  compasses  are  further  improved 
by  jointing  the  last  6  or  7  cm.  of  the  arms  by  means  of  a  small 
bolt  and  thumb  screw.  (Fig.  la.)  With  this  additional 
adjustment  the  rings  can  be  placed  in  contact  with  the  body 
in  any  position. 


Illustration  33. 
Antero-posterior  observation. 

In  the  first  method  the  compasses  are  used  in  the  following 
manner.  The  patient  is  first  placed,  if  a  horizontal  table  be 
used,  upon  his  back.  Long  sandbags  may  be  laid  under  the 
patient  on  either  side  of  the  area  of  localisation,  in  order  to 
permit  the  insertion  of  the  compasses  beneath  the  limb  or  body. 
Other  sandbags  may  be  adjusted  for  the  comfort  of  the  patient. 
(Illustration  33.)     Should  a  table  with  sliding  cross  panels  be 


46         X-Ray  Observations  for  Foreign  Bodies 

in  use,  one  of  these  panels  may  be  removed  to  provide  con- 
venient access.  Observations  in  the  antero-posterior  position 
are  made,  adjusting  the  compasses  in  such  a  manner  that  the 
foreign  body  appears  on  the  screen  encircled  by  the  rings. 
(Illustration  34,  Figs,  i  and  2.)  The  skin  is  marked  through 
these  rings  with  blue  grease  paint  and  the  patient  then  rotated. 
In  this  rotation  great  care  should  be  taken,  for  the  accuracy  of 


Q    (0) 


Illustration  34. 

Diagrammatic  Application  of  Compass,  Diaphragm  and  Arc. 

Fig.  I.     a,  b.  Normal  ray;    c,  d,  e,   f.    Oblique  rays;  g.   Diaphragm  with 

tubes ;   /'.  Closed  diaphragm  ;  /.  Open  diaphragm  ;  /.  X-ray  tube  ;  k.  Table  ; 

/.Foreign  body;    "/.Compass;    ».  Additional  hinges;    0.  Principal  hinge; 

p.  Patient. 
Fig.  2.     I.  Well  centred;    2.  Badly  centred  foreign  body. 
Fig.  3.     Arc  (for  use   at    operation) ;    I    and   3.  Probes   (in    position    on 
localisation  marks  on  skin) ;     2.  Measured  probe  (in  position  on  foreign 
body) ;  4.  Nut ;    5.  Thumb-screw. 

localisation  depends  upon  the  turningof  the  limb  or  the  body,  as 
one  would  turn  a  cylinder,  so  as  to  avoid  change  of  contour 
of  the  surface  anatomy.  If  such  a  change  takes  place  a  false 
relationship  between  the  foreign  body,  and  the  superficial 
markings  on  the  skin  will  result.  With  a  little  care,  however, 
and  in  the  case  of  the  body,  a  vertical  screening  stand,  this 
difficulty    will    not   occur.     Having   successfully   turned   the 


X-Ray  Observations  for  Foreign  Bodies         47 

patient,  the  foreign  body  is  again  encircled  with  the  rings  of 
the  compass  and  further  skin  markings  made  with  grease  paint 
of  another  colour.  This  marking  is  then  repeated  in  a  third 
position,  making  three  observations  in  all,  and  giving  six 
marks  of  three  colours  upon  the  skin. 

Production  of  the  Outline  Contour. 
Reference  should  now  be  made  to    Illustration  32,  Fig.  5, 
5<T,  and  $b — showing  strips   of    soft    malleable  metal,  which 


Illustration  35. 
Taking  the  contour  of  the  body  and  transferring  the  skin  markings  to  the 

metal  band. 

can  be  obtained  from  any  medical  electrical  warehouse. 
They  are  made  of  an  alloy  used  for  high  frequency  electrodes. 
The  strips  should  be  some  2  cm.  wide  for  the  limbs  and  4  cm. 
wide  for  the  body,  and  of  various  lengths,  sufficient  to  encircle 
the  different  circumferences  of  limbs  and  body.  They  are 
hinged   in  the   centre.       When    in    use    (Illustration  35)    the 


48 


X-Rav  Observations  for  Forei2:n  Bodies 


hinge  should  be  placed  upon  some  anatomical  landmark  to 
facilitate  reference ;  the  spinous  process  of  a  vertebra  is  very 
suitable  for  the  purpose.  ''Right"  or  "left,"  and  "anterior" 
■or  "  posterior,"  should  be  marked  upon  the  metal.  Care  must 
now  be  taken  to  mould  the  band  to  the  exact  contour  of  the 
body.  Where  the  metal  overlaps,  a  line  is  drawn  on  the 
band,  also  the  positions  of  the  coloured  markings  on  the  skin 
are  transferred  to  the  metal  band,  as  well  as  the  position  of  the 
w^ound  of  entrance   or   the  incidence    of   the    perpendicular 


Illustration  36. 
Transferring  the  contour  (and  markings)  to  paper. 


drawn  from  it.  The  metal  is  then  lifted,  great  care  being  taken 
to  see  that  the  contour  is  preserved,  and  placed  upon  a  sheet 
of  paper.  The  internal  contour  is  traced  with  a  pencil  on  to 
the  paper,  and  the  coloured  marks  are  transferred.  (Illustra- 
tion 36.)  The  anatomical  level  of  the  foreign  body  should  be 
noted,  and,  if  the  wound  of  entrance  is  not  in  the  same  plane, 
its  distance  superior  or  inferior  measured.  As  an  additional 
precaution,  until  the  worker  is  familiar  with  the  method,  large 
wooden  calipers  may  be  used  to  take  the  lateral  and  antero- 


X-Ray  Observations  for  Foreign  Bodies 


49 


posterior  measurements  of  the  body,  in  order  to  confirm  the 
shape  and  position  of  the  transferred  metal.  The  coloured 
marks  are  connected  with  the  aid  of  a  ruler,  and  if  care  has 
been  exercised  it  will  be  found  that  the  three  lines  intersect 
within  an  area  not  larger  than  the  foreign  body.  Should  this 
not  be  the  case  it  is  obvious  that  some  error  in  technique  has 
been  committed.  If  the  observations  have  been  correct,  the 
intersection  will  represent  the  position  of  the  foreign  body. 
The  grease  paint  marks  upon  the  skin  maybe  rendered  perma- 
nent by  nitrate  of  silver. 


Illustration  37. 
Geometrical  Method  of  Debierne. 


In  the  absence  of  metallic  bands,  recourse  may  be  taken  to  a 
geometrical  procedure  to  realise  graphically  the  position  of  the 
foreign  body,  from  two  readings  antero-posterior  and  oblique, 
taken  as  previously  described.*  Illustration  37  shows  A  A^ 
an  antero-posterior  observation,  B  B^  an  oblique  observation. 
To  transfer  to  paper,  the  distance  A  A^  is  measured  by  a  large 
pair  of  wooden  compasses  and  a  line  drawn  of  this  length,  a  a^' 
Large  ordinary  compasses  are  now  taken,  and  with  the  distance 
A  B  as  radius,  with  a  for  centre,  the  arc  <:/ is  described;  then 
with  the  distance  B  A^  as  radius,  and  rt^as  centre,  the  arc  e^  is 
described;  the  distance  A^  B^  is  now  taken  for  radius,  with  a^ 

*  Debierne.     Prcsse  Mid.,  Nc.  9,  March,  1915. 

E 


a? 


i. 


^ 


tf 


•-•  _j^50         X-Ray  Observations  for  Foreign  Bodies 

x*  ^     as  centre,  and  the  arc /'described;  and  with  the  distance -^4  B^ 
^  as  radius,  and  a  as  centre,  the  arc^  is  described.     The  intersec- 

^  tion  of  <7  rt'  by  the  Hne  b  b^  joining  the  intersections  of  the  two 
pairs  of  arcs  gives  the  position  of  the  foreign  body  with  regard 
to  the  marks  made,  but  does  not  give  the  distance  from  the 
skin  at  any  point  between  these  marks,  and  therefore  is  not 
nearly  so  practical  and  helpful  as  the  metal  band  method. 

Modifications  of  Technique. 

Before  passing  on  to  the  amplification  of  the  chart,  which 
gives  the  anatomical  location  of  the  foreign  body,  some 
modifications  may  be  suggested  which  may  be  preferred  by 
some  workers.  In  the  absence  of  compasses,  if  desired,  small 
rings  like  those  shown  in  Illustration  32,  Fig.  3,  3«,  can  be 
used.  These  rings,  which  may  be  of  various  sizes  and 
improvised  from  metal  washers,  are  first  placed  on  a  disc  of 
adhesive  plaster,  in  the  centre  of  which  is  a  hole  through 
which  to  mark  the  skin.  Illustration  32  shows  a  small  fluor- 
escent screen,  perforated  in  the  middle  (Fig.  4)  to  permit 
direct  anterior  marking  without  fixing  a  ring.  This  will  be 
found  a  very  useful  alternative,  as  it  saves  time. 

Another  modification  of  the  method,  necessitating  some 
additional  apparatus,  is  as  follows.  An  X-ray  tube  is  so  fixed 
that  it  can  be  brought  near  to  the  posterior  surface  of 
the  patient,  (it  might  here  be  noted  that  it  is  advisable,  in 
this  case,  to  protect  the  patient  by  a  sheet  of  aluminium.) 
A  long  displacement  of  the  tube  must  be  possible  in  the 
direction  across  the  patient.  The  tube  having  been  well 
centeiecl.  and  the  diaphragm  closed  down  upon  the  foreign 
body,  tlie  antero-posterior  position  is  marked  through  the 
compasses  cr  small  metal  rings,  as  already  described.  The 
tulie  ma\  ii^w  he  displaced  as  far  as  possible,  and  the 
dia;^l,r:i' m  -ipi-nt-d  to  include  the  foreign  body,  which  is  again 
en-i''-'  d  .iMi  tie  metallic  rings  and  marked;  the  observation 
i-    I  \'i:iCi  in    the  opposite   direction.      To  be  able   to 

vv(!'  I  I'.d  and  to  get  a  sufficient  angulation,  it  will   be 

I; HI.  \-    to    iKive    the   anticalhode   within     10   or    12 

ill'  .:  ii'nt.     The  time   occupied   in    making   these 


X-Ray  Observations  for  Foreign   Bodies         51 

observations  is  so  short,  however,  that  with  an  akiminium 
filter  there  is  no  risk  of  burns  if  rays  of  a  hard  type  are  used. 
A  big  advantage  of  this  modification  is  that  the  observations, 
providing  the  tube  has  been  accurately  centered,  will  always 
be  in  the  same  plane  without  the  slightest  deviation.  The 
proceeding  with  the  metal  band  is  identical  with  that  already 
described.  Some  difficulty  may  be  found  in  getting  a 
sufficient  displacement  of  the  tube.     Reference  to   Illustration 


Illustration  38. 

Tube  displacement  method   with  extemporised   bench  at  right  angles  to  X-raj' 

table  to  secure  the  long  displacement  across  the  patient  (central  position). 

38  will  show  a  means  whereby  it  is  possible  to  extemporise 
with  a  small  bench  placed  at  right  angles  to  the  X-ray  table, 
or  removable  flaps  may  be  adjusted  to  the  latter. 

Chart  Production  from  Localisation  by  Triangulation. 

If  it  is  desirable  to  use  the  triangulation  method  of  localisa- 
tion, in  the  case  of  a  very  sick   patient,  or   by  choice  of  the 


52         X-Ray  Observations  for  Foreign  Bodies 

operator,  the  tube  may  be  centered  under  the  foreign  body, 
and  the  anterior  and  posterior  marks  placed  upon  the  skin, 
after  which  a  plate  is  placed  over  the  anterior  mark  and  an 
exposure  made.  The  tube  is  then  displaced  to  a  known 
distance  and  a  second  exposure  made.  A  diagram  can  be 
made  for  the  purpose  of  calculating  the  depth  of  the  foreign 
body  on  the  line  of  the  normal  ray,  using  the  method  previously 
described  (Illustration  12).  The  contour  of  the  body,  at  the 
level  of  the  markings,  should  now  be  taken  and  transferred  to  a 
sheet  of  paper,  with  the  antero-posterior  markings;  these  are 
connected  by  a  line,  and  the  calculated  position  of  the  foreign 
body  recorded.  Other  marks  may  now  be  placed  upon  the 
outlined  contour,  in  such  a  manner  that  lines  drawn  through 
them  will  intersect  at  the  position  of  the  foreign  body;  the 
marks  are  then  transferred  to  the  skin  by  replacing  the  malle- 
able metal  band.  In  this  way  choice  of  entrance,  with  fixing 
points  for  mechanical  guidance,  will  be  available  at  the 
operation,  and  the  advantage  of  a  cross  section  anatomy- 
utilised. 

Anatomical  Localisation  by  Amplification  of 
THE  Chart. 

Whichever  method  may  have  been  chosen  for  the  produc- 
tion of  the  skin  markings,  the  procedure  for  transferring  them 
and  the  contour  of  the  limbs  or  body  on  to  paper  is  the  same,, 
and  the  same  intersecting  lines  are  drawn.  The  cross  section 
anatomical  details  of  the  area  at  the  level  of  the  foreign  body 
may  then  be  filled  in.  Reference  to  Illustration  39  will  show 
in  what  manner  these  graphic  amplifications  may  be  made. 
A  line  may  also  be  drawn  showing  the  path  of  the  projectile,, 
and  the  chart  wall  thus  disclose,  not  only  the  anatomical 
situation  of  the  foreign  body,  but  also  the  route  it  has  taken 
to  reach  its  position,  as  well  as  any  vessels  or  organs  which 
may  have  been  injured  in  its  transit.  In  the  event  of  the 
wound  being  somewhat  remote,  other  cross  section  diagrams 
at  intervals  will  be  of  considerable  help,  or,  if  a  sagittal  section 
of  the  area  is  available,  work  may  be  saved  by  referring  to  it. 

An  example  of  such  a  reconstruction  of  the  wound  tracks 


X-Rav  Observations  for  Foreiirn  Bodies 


53 


in  successive  sections,  is  shown  in  the  frontispiece.  In  this 
case  the  wound  of  entrance  was  between  the  seventh  and 
eighth  ribs,  at  the  level  of  Section  27  in  Eyclesheymer  and 
Schoemaker's  Atlas,  while  the  foreign  body  was  localised 
between  Sections  31  and  32,  and  the  intermediate  sections  are 
shown,  with  the  path  of  the  projectile  reconstructed.  The 
sections  are  traced  from  the  atlas  on  ordinary  tracing  paper, 
and  the  reconstruction  is  carried  out  w^ith  the  help  of  a  scale 
diagram,  as  shown  in  P"ig.  i.  The  width  of  the  patient  is 
measured  at  the  level  of  the  foreign  body,  and  the  width  of 
the  atlas  section  at  the  same  level  is  also  measured.  The 
localisation  has  already  given  the  lateral  distance  to  which  the 


Mnul  4  otfaMt 


Aat. 


,V.rUt»<i  Ikorac.lvt  E 


Illxistration  39. 
The  anatomical  amplification  of  the  chart. 

foreign  body  has  penetrated,  and  the  corresponding  distance 
on  the  scale  of  the  chart  is  worked  out  from  the  two  measure- 
ments just  made  by  simple  proportion.  These  two  distances 
can  be  marked  off  along  a  horizontal  straight  line,  as  OA  and 
OB  in  the  figure.  A  second  line,  OC,  is  then  drawn  at  right 
angles  to  this,  along  which  the  distances  separating  the  required 
sections  of  the  chart  can  be  measured  off.  Thus,  in  the  case 
shown,  the  foreign  body  was  localised  10  mm.  below  Section 
3  I ;  26  mm,  separate  Sections  30  and  31,  etc.  From  the  points 
so  marked  along  the  vertical,  horizontal  lines  are  draw^n  parallel 
to  OA,  and  a  straight  line  CB  is  drawn  cutting  these.     Since 


54         X-Ray  Observations  for  Foreign  Bodies 

the  wound  of  entrance  is  at  Section  27,  and  the  foreign  body 
at  a  point  represented  by  B,  between  Sections  31  and  32,  the 
lengths  cut  off  by  CB  along  the  horizontal  lines  represent  the 
depths  to  which  the  foreign  body  has  penetrated  at  each  level^ 
on  the  scale  of  the  chart.  All  that  is  now  needed  is  to  rule  on 
tracing  paper  a  line  of  the  length  OB,  and  placing  it  in  turn 
over  the  horizontal  lines  of  the  chart,  prick  through  with  a  pin 
the  successive  distances  of  penetration.  The  positions  of  the 
wound  of  entrance  and  of  the  foreign  body  are  marked  on  the 
first  and  last  sections  respectively ;  then  all  the  sections  are 
superposed,  with  the  straight  line  arranged  over  them  so  as  to 
run  from  the  wound  to  the  foreign  body.  The  pin  holes  are 
pricked  through,  and  the  appropriate  points  on  each  section 
being  joined  by  a  thick  straight  line,  we  have  the  path  of  the 
projectile  through  each  region  of  the  body,  and  it  is  at  once 
evident  what  organs  are  probably  involved.  The  subsequent 
history  of  this  patient  showed  that  all  the  organs  through 
which  the  wound  track  passes  in  the  charts  were  actually 
injured,  except  the  aorta,  which  was  evidently  just  missed. 

With  charts  constructed  in  this  way  the  surgeon  has  definite 
information  as  to  the  exact  position  of  the  foreign  bod}^,  with 
full  confidence  in  the  absolute  accuracy  of  its  localisation.  He. 
also  knows  the  position  of  organs  or  vessels  of  surgical  import- 
ance, near  or  distant,  and  by  a  glance  at  this  chart  the  easiest 
approach  for  removal  of  the  foreign  body  is  at  once  obvious. 
If  it  has  been  observed  in  the  radiograph  that  a  bone,  not  in 
the  direct  course  from  wound  to  projectile,  has  been  injured, 
the  path  of  the  projectile  would  be  from  wound  to  injury  and 
from  bone  injury  to  localisation.  This  chart,  when  so  pre- 
pared in  conjunction  with  a  report  of  the  general  findings, 
provides  the  surgeon  with  the  most  valuable  document  possible, 
and  one  in  which  he  can  have  the  utmost  confidence,  and 
attached  to  the  history  of  the  patient  it  forms  a  permanent 
record.  This  is  particularly  desirable  should  it  be  deemed 
inadvisable  to  operate.  A  copy  accompanying  the  patient's 
evacuation  papers  will  safeguard  the  patient  and  obviate  further 
observation  at  another  hospital,  or  constitute  in  the  most 
acceptable  form  the  information  necessary  for  a  decision  to  be 


X-Ray  Observations  for  Foreign  Bodies         55 

made  by  a  Medical  Board.  Transparent  paper  can,  of  course, 
be  used  rn  the  prepaiation  of  these  diagrams,  so  that  if  desired, 
they  can  be  superimposed  on  a  cross  section  atlas  and  the 
anatomical  details  traced  in.  Eyclesheymer  and  Schoemaker's 
Atlas  is  very  suitable  for  this  purpose.  Such  an  atlas  should 
be  available  in  every  department. 

Localisation  of  Foreign  Bodies  in  the  Head. 

Additional  precautions  are  necessary  for  the  localisation  of 
a  foreign  body  in  the  head.  An  exact  localisation  can  be  made 
by  using  a  length  of  wire  to  embrace  the  circumference  of 
the  head,  and  fixing  it  so  as  to  mark  out  a  horizontal  plane 
passing  through  the  two  marks  of  the  first  observation.  It  is 
then  possible,  during  the  subsequent  fluoroscopic  observations 


Illustration  40. 

Localisation  chart  of  the  head,  showing  the  contour  of  the 

dome  g  added  to  the  localisation  line  c  f. 

to  turn  the  head  in  such  a  manner  as  to  maintain  the  same 
plane,  and  to  adjust  the  position  so  that  the  wire  intersects  the 
shadow  of  the  foreign  body  as  a  line  and  does  not  appear  on 
each  side  as  an  ellipse.  (This  same  technique  may  be  applied 
with  profit  when  making  localisations  with  the  open 
diaphragm,  as  in  the  first  method,  p.  42.)  In  other  respects 
the  procedure  is   the  same  as   that  already  described. 

Further  localisation  observations  for  foreign  bodies  in  the 
head  can  be  made  by  means  of  the  strip  of  soft  metal  used  for 


56         X-Ray  Observations  for  Foreign  Bodies 

transferring  contours.  (Illustration  32,  Fig.  5.)  To  give 
additional  information  as  to  the  position  of  the  foreign  body 
in  relation  to  the  vault,  the  metal  should  be  placed  so  as  to 
take  the  contour  of  the  dome  of  the  head  vertically  over  any 
pair  of  localisation  marks  (Illustration  40,  ab,  dd,  or,  as  here 
shown,  ef^  The  points  chosen  should  be  those  best  suited  to 
whatever  sagittal  sections  one  may  have  at  hand.  This  contour 
can  then  be  added  to  the  same  localisation  line  on  the  chart, 
so  that  we  now  have  the  foreign  body  localised  in  a  vertical 


Illustration  41. 

Chart  of  a    foreign  body  localised  at  the  level  of   the  second  dorsal 

vertebra— access   is   impossible  posteriorly;    therefore  the  contour  is 

taken  vertically  over  the  shoul  ler  from  the  antero-posterior  observation 

and  the  arc  adjusted  as  illustrated. 

plane  also,  and  its  distance  can  be  measured  from  any  point 
of  the  vault  in  this  plane.  A  line  drawn  from  the  foreign  body, 
either  to  the  part  of  the  skull  through  which  the  surgeon  wishes 
to  trephine,  or  to  the  wound  of  entrance,  gives  the  required 
direction  for  the  mechanical  guide  described  below.  If  a 
localisation  observation  does  not  intersect  the  wound,  or  the 


58         X-Rav  Observations  for  Foreign    Bodies 

most  practical  point  of  entrance,  an  additional  observation  can 
be  made  for  the  purpose  in  such  a  direction  that  a  vertical  plane 
through  it  will  include  both  the  foreign  body  and  the  required 
point.  A  small  metal  disc  placed  over  this  point  will  render 
it  visible  on  the  fluorescent  screen,  and  thus  enable  the  required 
direction  to  be  accurately  determined.  It  will  thus  be  seen 
that  by  means  of  this  fourth  observation  the  foreign  body  may 
be  reached  definitely  through  any  desired  point  or  previous 
opening.  When  a  localisation  is  not  required  to  one  particular 
point,  the  shortest  line  of  approach  from  the  vault  to  the 
foreign  body  is  obvious  from  the  chart,  and  this  gives  the 
point  of  entrance,  which  can  be  marked  on  the  scalp  by 
replacing  the  metal  band.  This  same  technique  can  be  applied 
with  profit  to  the  shoulder  and  other  parts  of  the  anatomy. 
(Illustration  41  and  Plate  2..) 

Mechanical  Guidance. 

Several  forms  of  apparatus  for  supplying  such  guidance 
have  been  devised.  A  simple  and  convenient  one  is  the  arc 
shown  in  Illustration  34,  Fig.  III.  It  is  made  of  metal,  and  is 
constructed  to  take  three  movable  fittings,  each  being  bored 
for  the  passage  of  a  probe.  These  fittings,  which  are  in  the 
form  of  composite  nuts  (Fig.  Ill,  4),  can  be  firmly  fixed  in  any 
position  on  the  arc,  while  the  probes  (i,  2,  and  3)  are  still  left 
perfectly  independent  and  free  to  be  fixed,  in  any  position,  by 
a  separate  thumb  screw  (Fig.  Ill,  5)  fitted  in  the  nut.  One  of 
the  probes  (2)  is  marked  in  millimetres.  To  use  the  arc,  it 
is  laid  flat  on  the  localisation  diagram;  the  measured  probe  is 
placed  on  the  point  corresponding  to  that  chosen  by  the 
surgeon  for  his  incision,  and  directed  towards  the  foreign 
body,  and  the  points  of  the  other  two  probes  are  placed  on 
any  other  two  localisation  marks  within  reach.  The  nuts  and 
screws  of  the  latter  are  now  firmly  fixed,  the  nut  alone  of  the 
measured  probe  is  made  secure,  and  this  probe  when  pushed 
forwards  must  arrive  at  the  position  indicated  as  that  of  the 
foreign  bod}'.  Notice  is  taken  by  the  surgeon  of  the  exact 
depth  of  the  foreign  body,  as  indicated  on  the  diagram,  then 
the  measured  probe  will  show  the  depth  to  which  the  incision 


X-Rav  Observations  for  Foreign  Bodies 


59 


must  be  carried  to  reach  it  (Illustraticn-i  41).  The  arc  is  then 
steriHsed.  This  simple  apparatus  can  be  ph'ced  on  tlic  marks 
in  the  field  of  operation,  and  as  the  incision  is  made  the 
central  probe  will  mechanically  follow,  until,  at  the  depth 
previously  ascertained,  it  touches  the  foreign  body  (Illustra- 
tion 42). 

It  has  been  found  possible,  in  suitable  situations,  to  take  ^c 
sharp  pointed  probe  or  cutting  needle,  and  by  inserting  this 


Illustration  42. 
The  arc  in  the  field  of  operation. 

along  the  line  between  the  localising  points,  to  push  it  home 
to  strike  the  foreign  body.  Contact  may  be  controlled  by 
attaching  the  telephone  probe  described  later.  This  makes 
extraction  possible  through  the  smallest  incision. 

Care  should  be  taken  in  all  circumstances  to  place  the 
patient  upon  the  operating  table  in  the  exact  position  he 
occupied  when  the  markings  were  made.  Although  this  is 
not  so  important  as  in  most  other  methods  of  localisation,  it 
is  obvious,  for  instance,  that  a  localisation  made  in  pronation 


6o         X-Rav  Observations  for   Foreign  Bodies 

would  be  invalidated  should  the  operation  be  performed  with 
the  limb  flexed  or  in  supination. 

Compass  of  Hirtz.* 

While  originally  designed  for  use  with  a  more  intricate  and 
tedious  technique,  this  compass  is  nevertheless  admirably 
adapted  for  use  as  a  mechanical  guide  for  removal  of  foreign 
bodies,  and  can  be  emploved  with  almost  any  method  of 
localisation  when  the  foreign  body  is  of  known  depth  vertically 
below  a  given  mark. 

The  compass  will  be  seen  in  Illustration  43.  It  is  placed 
upon  the  patient  and  the  three  legs  regulated  so  that  the  point 
of  the  central  indicator  is  on  the  localisation  mark  and  is  per- 
pendicular (Fig  i);  the  legs  should  rest  on  bony  structures  when 
possible.  The  illustration  shows  an  arc  which  can  be  attached 
so  as  to  turn  about  the  centre  of  the  apparatus ;  the  legs  of  the 
compass  are  then  regulated  so  that  the  foreign  body  becomes 
the  centre  of  the  circle  of  which  the  arc  is  a  segment.  The 
arc  rotates  on  its  attachment  in  such  a  way  that  its  centre 
remains  unaltered  ;  the  probe  can  be  attached  to  the  arc  by  a 
sliding  nut,  which  keeps  it  lying  always  along  a  radius,  and  there- 
fore, as  it  moves  round  the  arc,  it  is  always  directed  at  the 
position  of  the  foreign  body,  and  so  gives  a  choice  of  position 
for  the  operative  incision  within  a  considerable  range.     (Fig.  2.) 

Removal  of  Foreign  Bodies  under  Fluorescent 

Screen. t 

In  every  hospital  serious  consideration  should  be  given  to 

this  method;    it  can  be  carried  out  in  the  operating  theatre,  in 

the  X-ray  department,  or  best  in  a  room  specially  equipped 

and  set  apart  for  the  purpose. 

In  any  case  it  may  not  be  necessary  to  duplicate  the  installa- 
tion if  the  X-ray  department  is,  as  it  should  be,  next  to  or  not 
too  remote  from  the  operating  theatre.     The  current  for  the 

*  A.  Charlier,  Jonnial  de  Radiologic  et  d' Elcctioilu  rapic,  A^prW,  1915. 
E.  Hirtz,  loc.  cit.,  Jan.,  1916. 
Morin  et  H.  Beclere,  loc.  cit.,  Jan.,  1916. 
Morin,  loc.  cit.-,  Nov.,  1916. 

t  "L'Extraction  des  Projectiles  a  I'AideduControle  Intermittent  del'Ecran," 
par  L.  Ombredanne  et  R.  Ledoux-Lebard.  Join  iial  dc  Radiologic  et 
d' Elect.,  March,  1916. 


X-Ray  Observations  for  Foreign  Bodies         6i 


62         X-Ray  Observations  for  Foreign  Bodies 

tube  may  be  obtained  by  carrying  an  overhead  set  of  trolley 
wires  through  the  wall  of  the  operating  room,  so  that  only  the 
table,  connections  to  the  tube,  and  controlling  switch  to  the 
primary  of  the  coil  need  be  in  the  operating  room.  Of  course, 
if  the  operating  room  cannot  be  darkened,  a  cryptoscope 
must  be  used;  the  type  in  Illustration  44  is  most  suitable,  and 
can  be  covered  with  a  sterile  cover.  It  provides,  when  lifted, 
a  violet  glass  protecting  the  surgeon's  eyes  from  loss  of  adapt- 
ation. In  this  \\av  intermittent  or  continual  screen  control 
can  be  obtained. 

If  distance  or  slructural  difhculties  prevent  the  realisation  of 
this  suggestion,  and  a  portable  X-ray  installation,  such  as  is 
used  for  the  verification  of  position  of  fractures  in  the  wards, 
is  part  of  the  equipment,  then  of  couise  the  difficulty  can  be 
overcome  by  its  introduction  into  tlie  theatre  when  needed. 
However,  so  much  good  work  has  been  done  by  this  technique, 
that  n:iany  hospitals  have  foimu  it  desirable  to  equip  a  radio- 
surgical  room  with  its  (jwn  installation.  A  special  table  should 
be  provided,  witli  ample  protection  to  surgeon,  assistants,  and 
anaesthetist,  in  tlie  U)rm  of  lead  sheets,  The  illumination, 
preferablv  entirelv  electric,  is  provided  bv  two  separate  clusters 
of  high  candle  power  lamps,  under  a  foot  control  by  the  surgeon 
or  his  assistant;  one  group  is  white  while  the  second  is  red  or 
violet.  The  controlling  foot  switch,  in  its  central  position, 
illuminates  the  room  with  the  red  light,  moved  to  the  left  it 
operates  the  tube,  and  to  the  right  it  puts  in  circuit  the  white 
light.  In  tliis  manner  the  surgeon  or  his  assistant  (preferablv 
the  radiographer)  has  full  control. 

In  practice,  the  patient  is  placed  on  the  table  for  operation  and 
anaesthetised,  the  tube  roughly  adjusted  to  the  area  of  opera- 
tion, and  the  sterile  field  prepared,  draped  preferably  with  a 
large  sheet,  with  a  central  aperture  for  the  operation.  The 
sheet  should  hang  dcnvn  ovt-r  the  tube  and  diaphragm  controls, 
which  can  then  be  adjusted  bv  the  surgeon  himself  from  time 
to  time,  if  necessaiy,  during  the  operation.  The  latter  part  of 
the  work  can  be  carried  out  in  a  red  light,  and  when  all  is  ready, 
and  the  tube  is  switched  un  and  the  light  out,  perfect  vision 
will  be  a  matter  of  onlv  a  lew  seconds. 


X-Ray  Observations  for  Foreign  Bodies 


63 


The  points  of  iuipoitance  are  the  protection  of  operators,  a 
tube    weH    covered   with  a  small  diaphragm  and    rigorously 


centered    to    ensure    faithful    projection  of    the    image,   long- 
handled  instruments  to  keep  the   hands  out  of  the  pencil   of 


64 


X-Rav  Observations  for  Foreign   Bodies 

J  o 


rays  in  use,  hard  rays,  and  a  sheet  of  aluminium,  or  preferably 
a  table  with  an  aluminium  top,  to  protect  the  patient. 

The  screen  is  best  supported  by  an  independent  upright ; 
when  the  foreign  body  is  located  the  large  screen  may  be 
exchanged  for  a  smaller  one,  of  some  lo  cm.  square,  enclosed 
in  a  sterile  bag,  faced  on  the  upper  side  with  a  celluloid  window. 
Arranged  in  this  manner  it  is  but  a  small  encumbrance  to  the 
surgical  field. 

This  method  has  much  in  its  favour  for  the  removal  of 
multiple  lead  splutterings,  and  superficial   foreign   bodies  that 


Illustration  45. 

a.  Canula;  h.  Sharp  trocar ;  c.  Blunt  trocar;  (/.  Fine  stiff  wire  with 

barbed  end. 

do  not  vibrate,  while  the  control  it  offers  in  difficult  cases  can 
hardly  be  dispensed  with  if  one  would  be  always  successful. 
Foreign  bodies  in  the  lung  that  are  operable  are  successfully 
removed  by  this  technique  in  conjunction  with  a  geometrical 
and  anatomical  localisation.  As  practised  by  Dr.  Petit  de  la 
Villeon,'*  when  once  the  skin  is  penetrated  an  alligator  forceps 
is  pushed  through  the  pleura  and  into  the  lung  until  it  touches 
the  foreign  body;  when  the  forceps  miss  the  foreign  body, 
further  observation  is  required  to  adjust  their  position;  this 
may  be  done  by  displacement  of  the  tube,  or,  as  preferred  by 
the  author  of  this  operation,  by  a  rotation  of  the  patient  on  his 
*  Pvcssc  Mcdiciilc  May  3 1,  1917. 


X-Ray  Observations  for  Foreign  Bodies         65 

long  axis,  for  which  purpose  a  simple  table  has  been  made,  the 
top  of  which  pivots  at  will. 

Sutton's  Probes. 

Closely  allied  to  the  preceding  is  the  use  of  this  little  appli- 
ance, comprishig  a  canula  graduated  in  cm.  and  provided  with 
a  pointed  and  a  blunt  trocar  (Illustration  45),  which  are  supple- 
mented with  some  lengths  of  stiff  wire  crooked  at  the  ends. 


Illustration  46. 
Bergonie  vibrator  with  moving  scaffold. 

In  use,  the  sharp  trocar  and  canula  is  introduced  under 
local  or  general  anaesthetic,  if  necessary;  and  under  control 
of  the  screen,  the  point  of  the  trocar  is  placed  on  the  skin 
coinciding  exactly  with  the  shadow  of  the  foreign  body,  with 
the  tube  rigorously  centered   and  the   diaphragm  shut  down. 

F 


66         X-Ray  Observations  for  Foreign  Bodies 

Holding  the  canula  and  trocar  vertically,  the  point  is  intro- 
duced through  the  skin  and  the  sharp  troCar  then  exchanged 
for  the  blunt  one,  which  is  gradually  advanced  until  the  foreign 
body  is  reached  ;  at  this  point  the  trocar  is  removed  leaving 
the  canula  in  contact.  Through  the  latter  is  threaded  one  of 
the  wires,  which  being  retained  by  its  hooked  end  catching  in 
the  tissues,  permits  the  canula  to  be  removed  without  disturb- 
ing the  relation  of  the  wire  to  the  foreign  body.  The  patient 
is  then  taken  to  the  operating  room  and  the  wire  used  as  a 
guide  to  the  foreign  body. 

Bergonie  Vibrator. 

This  is  a  large  powerful  electro  magnet,  actuated  by  alter- 
nating current,  and  requires  for  its  effectual  working  some  60 
amperes,  at  no  volts,  with  a  periodicity  of  about  50.  When 
in  operation,  a  heavy  magnetic  field  of  attraction  and  repulsion 
is  produced  over  the  area  of  its  core. 

In  construction  it  is  a  heavy  core  of  iron  wires,  about  one 
end  of  which  is  wound  a  coil  of  many  turns.  It  is  suspended 
from  the  ceiling,  wall  bracket,  or  movable  scaffold,  and  presents 
the  appearance  shown  in  Illustration  46. 

When  a  magnetisable  foreign  body  is  brought  within  the 
rising  and  falling  magnetic  field,  it  pulsates  in  rhythm  with  the 
periodicity  of  the  current  in  use. 

To  locate  a  projectile,  the  hand  is  placed  on  the  limb  and 
the  vibrator  approached  as  near  as  possible  to  the  back  of  the 
fingers  without  touching  (Illustration  47,  Fig.  i).  If  no 
vibration  is  felt  the  hand  or  fingers  are  pressed  more  firmly 
into  the  tissues.  When  found,  the  point  of  maximum  vibration 
is  located  with  one  finger,  and  the  skin  at  this  point  marked 
to  save  time  in  relocating  at  the  operation.  A  simple  wooden 
table  is  preferable,  to  avoid  the  disturbance  of  the  magnetic 
field  which  is  caused  by  one  of  iron,  and  the  limb  should  be 
so  placed  that  muscles  are  relaxed  and  flaccid,  so  as  to  impose 
as  little  resistance  to  the  pulsation  as  possible. 

At  the  operation  the  vibrator  should  be  provided  with  a 
sterile  cover.  The  surgeon  should  confirm  the  previous 
localisation  mark  made,  and  make  the  incision  through  it,  if 


X-Ray  Observations   for  Foreign  Bodies         67 

possible,  progress  being  directed  by  repeated  applications  of 
the  vibrator,  the  pulsation  increasing  as  the  fragment  is 
approached  (see  Illustration  47,  F'ig.  2). 

It  is  also  useful,  during  an  operation,  in  finding  foreign  bodies 
which    have  been    otherwise    localised,  and  which    were  too 
deep  to  be  vibrated  until  approached  in  the  operation. 
.     It  is  obvious  that   this   procedure   is   only  practicable  with 


Fig.  I.  Fig.  2. 

Illustration  47. 
Fig.  I.     General  Exploration.  Fig.  2.     Exploration  of  a  wound. 

metals  or  alloys  that  will  respond  to  the  magnetic  field,  but, 
with  the  exception  of  lead,  most  other  projectiles  will  respond 
"to  a  greater  or  lesser  degree.  Some  skill  in  touch  will  be 
required  to  appreciate  the  vibration  of  a  tiny  fragment.  Non- 
magnetisable  clamps  must  be  provided,  or  vessels  ligatured 
and  instruinents  removed,  before  bringing  the  vibrator  into 
;the  field  of  operation.     It  must  be  realised  that  it  is  only  a 


68 


X-Ray  Observations  for  Foreign  Bodies 


vibrator,  and  will  not  attract  and  withdraw  a  projectile  from 
a  wound. 

The  vibrator  heats  rapidly  from  the  heavy  current,  and  it 
must  be  cut  off  frequently  to  allow  it  to  cool.  No  individual 
seance  should  be  longer  than  two  minutes. 

A  second  form  of  this  magnet,  modified  in  its  winding,  and 
with  the  addition  of  condensers,  is  an  advantage  where  the 


Illustration  48. 
Electric  probe  in  use. 

alternating  main  does  not  change  its  pressure  to  a  marked 
degree.  Should  this  occur,  the  condensers  are  liable  to  break 
down  and  give  trouble  ;  otherwise  it  is  to  be  preferred.  It  is 
quite  as  powerful,  if  not  more  so,  and  the  current  consumption 
being  only  about  f  amps.,  it  can  be  run  for  a  longer  period 
without  rest. 


X-Ray  Observations  for   Foreign  Bodies         69 

Telephone  Probe. 

This  is  a  valuable  addition  to  the  surgeon's  equipment,  and 
should  always  be  at  hand  in  all  operations  for  removal  of 
foreign  bodies.  By  its  use  he  is  enabled  to  differentiate 
metallic  substances  embedded  in  the  tissues  from  bony 
structures  or  fragments  that  may  be  near  to  or  surrounding 
the  foreign  body  ;  it  is  very  simple  in  construction  and  in 
use. 

It  comprises  a  telephone  receiver,  double  for  preference, 
mounted  on  a  head  piece  (Illustration  48,  A).  Connected  to 
the  receiver  are  flexible  insulated  wires,  about  2  metres  long; 
to  one  is  connected  a  carbon  plate  {B),  about  14  by  5  cm.  (a 
bichromate  battery  carbon  will  do  well).  The  other  flexible 
wire  is  best  provided  with  some  simple  connection  (C)  to 
which  can  be  easily  attached  an  additional  length  (about  50 
cm.)  of  sterilisable  flex,  provided  at  its  other  end  with  a  clip 
{D)  to  grip  instruments  in  the  field  of  operation. 

The  detachable  section  of  flex  is  sterilised  with  the  surgical 
instruments.  The  carbon  plate  is  wrapped  in  gauze  and  well 
saturated  with  a  strong  solution  of  common  salt  and  fixed  by 
a  bandage,  or  placed  under  the  patient  in  good  contact  with 
the  skin.  The  axilla  and  between  the  thighs  are  good  positions 
when  possible  ;  the  moisture  provided  by  the  large  glands 
reduces  the  resistance  to  the  current.  If  preferred,  a  round 
rectal  electrode  may  be  provided.  The  receiver  is  placed  upon 
the  surgeon's  head  and  the  sterile  section  connected  up.  Any 
surgical  instrument  can  now  be  brought  into  the  circuit  by 
attaching  it  to  the  spring  clip.  When  the  instrument,  so 
attached,  is  introduced  into  a  wound,  a  momentary  contact 
with  a  metallic  foreign  body  will  declare  itself  byaclicking  sound 
in  the  earpiece,  or  a  grating  sound  will  be  produced  by  a  rubbing 
contact,  a  small  current  being  generated  sufficient  to  actuate 
the  receiver.  The  body  forms  the  electrolyte  between  the 
(positive)  carbon  plate  and  (negative)  foreign  body.  Should 
a  probe  have  been  used  to  explore  it  may  be  replaced  by  forceps 
and  the  extraction  controlled  in  the  same  manner. 

Care  should  be  taken  that  the  operator  is  not  confused  by 
touching  other  instruments  in   the   field,    and  mistaking  the 


JO         X-Ray  Observations  for   Foreign  Bodies 

sound  for  contact  with  the  foreign  bod}^  Retractors  and 
clamps  are  best  removed;  the  telephone  can  be  tested  for  its 
efficiency  at  any  time  by  contact  with  an  instrument  in  the 
wound. 

La  Baume  Magnetic  Finger  Cot. 
(For  use  at  Operation.) 

This  apparatus,  while  not  so  useful  as  the  probe,  yet  has  its 
sphere  in  locating  foreign  bodies  in  the  pleural  cavity  or 
abdomen,  or  exploring  a  large  wound  in  which  a  foreign  body 
may  be  free.  It  lacks  the  sense  of  definite  direction,  but  is 
very  convenient  for  exploration,  as  it  renders  audible  a 
metallic  fragment  at  a  distance  of  about  i  )4  cm.  The  volume 
of  sound  increases  as  the  distance  separating  the  finger  cot 
and  the  foreign  body  is  decreased.  It  is  particularly  useful 
should  a  foreign  body  be  lost  in  a  cavity,  or  an  incision 
carried  beyond  the  depth  at  which  a  fragment  has  been 
localised,  to  disclose  on  which  side  the  foreign  body 
lies. 

Suggestions  to  X-ray  Operators. 

Examinations  should  be  made  as  exhaustive  as  possible  to 
prevent  the  necessity  of  repetition. 

Every  report  and  localisation  chart  should  bear  the  date  and 
the  serial  number  of  the  patient. 

Reports  on  first  observations  for  foreign  bodies  should  state 
if  in  the  radiographer's  opinion  they  will  vibrate.  They  should 
be  vibrated  by  the  doctor  in  charge  of  the  case  who  will 
subsequently  operate.  His  knowledge  of  the  case  and  previous 
marking  up  will  be  useful.  If  the  foreign  body  does  not 
vibrate  it  must  then  be  localised. 

Reports  of  foreign  bodies  should  state  all  the  definite 
information  ascertained,  and  ambiguity  should  be  avoided.  If 
plates  were  taken  it  should  be  stated,  and  their  direction 
mentioned.  The  size  of  the  foreign  body  should  be  given,  and 
in  what  tissues  it  lies,  soft  or  bony,  etc.  All  localisations 
should  be  both  geometrical  and  anatomical,  and  be  accom- 
panied by  a  chart  marked  with  "right,"  ''left,"  "anterior," 


X-Ray  Observations  for  Foreign   Bodies         71 

"posterior,"  and  any  other  necessary  information,  such  as  the 
vertebral  level  in  the  case  of  the  trunk.  The  chart  should  also 
be  marked,  when  possible,  with  the  wound  of  entrance.  The 
report  should  include  the  nature  of  the  projectile,  viz.,  piece  of 
shell,  rifle  bullet,  shrapnel  ball,  etc.,  and  its  size;  if  it  moves 
with  respiration,  arterial  pulsation,  flexion,  extension;  if  it  can 
be  felt  or  moved  frcjm  the  skin,  and  in  what  tissue  it  is  em- 
bedded. In  all  difficult  and  serious  cases  some  effort  should 
be  made  to  check  the  findings,  and  in  the  transferred  contour 
method  no  foreign  body  should  be  considered-  localised  if  the 
three  lines  do  not  intersect  within  the  area  of  the  foreign  body 
and  in  the  same  plane.  All  localisations  should  state  the 
position  of  the  limb  or  body  when  the  observations  were  made. 

Nitrate  of  silver  sticks  may  be  used  for  marking  the  skin, 
and  if  it  is  desired  to  render  the  marks  visible  at  once  they 
may  be  touched  with  photographic  developer;  this  in  some 
measure  will  help  to  prevent  blistering.  The  mark  should  be 
made  small  and  as  neat  as  possible;  indelible  ink,  or  tattooing 
with  Chinese  ink,  has  been  resorted  to;  the  ideal  marker  has 
not  yet  been  found. 

The  doctor  in  charge  of  the  case  should  see  that  these  marks 
are  kept  up,  and  the  nurse  warned  that  they  are  not  to  be 
accidentally  scrubbed  off  in  the  surgical  preparation.  Nothing 
is  more  annoying  to  all  concerned  than  the  arrival  of  a  patient 
on  the  table  with  his  marks  carefully  removed. 

Cases  for  localisation  with  open  wounds  should  be  sealed 
with  collodion  dressings  as  small  as  possible. 

The  surgeon  should  make  himself  thoroughly  acquainted 
with  the  localisation  data  and  skin  markings  before  the  opera- 
tion, and  with  the  principles  and  methods  employed,  that  he 
may  be  able  to  appreciate  and  use  the  information  placed  at 
his  disposal. 

Where  possible,  surgical  approach  should  be  made  to  a 
foreign  body  from  the  aspect  that  presents  the  largest  surface. 


72         X-Ray   Observations  for  Foreign  Bodies 


APPENDIX  I. 

AN  AUXILIARY  SWITCH-BOARD  AS  AN, AID  TO 

SHORT  EXPOSURES. 

A  large  number  of  hospitals   are  equipped   with  their  own 
electric  lighting  plant  and  are  far  removed  from  electric  mains. 


Illustration  49. 
Wiring  of  the  Switch-Board  for  1 5  amps. 
B.B.     Main    terminals   connected   to   arrival  terminals  of  main  to  X-ray 
I    8   118  installation. 
A. A.    Fuses. 

D.!!^  Double  pole  knife  switch. 
C.C.     Connection  to  primary  closing  switch  of  control  of  X-ray  installation. 

and  are  not  provided  with  accumulators.     This  condition  often 
places   the  X-ray    department  at   a  disadvantage   for  making 


X-Rav  Observations  for   Foreign  Bodies         73 


Illustration  50. 
Shows  the  installation  and  general  connection  complete. 

On  the  left  will  be  seen  the  lamp  board. 
Connection  on  the  right  to  main. 
Connection  on  the  left  to  primary. 


74         X-Ray  Observations  for  Foreign  Bodies 

short  exposures  so  necessary  in  chest  and  kidney  work,  the 
reason  being  that  hardly  ever  is  a  compound  wound  dynamo 
installed,  but  a  series  or  shunt  type  which,  although  perfectly 
satisfactory  for  lighting,  will  not  respond  to  an  instantaneous 
call  of  the  necessary  current  without  a  heavy  fall  in  voltage, 
and  by  the  time  that  the  engineer  or  automatic  regulator  has 
been  able  to  speed  up  to  the  demand,  the  radiographer's 
opportunity  has  passed. 

Being  similarly  situated  at  one  time,  and  explaining  to  an 
assistant  why  we  were  unable  to  use  the  intensive  switch  and 
small  self-induction  on  our  apparatus,  I  happened  to  say  that 
if  the  department  had  the  control  of  the  house  lighting  switch, 
and  could  simultaneously  switch  out  the  house  light  and  divert 
the  current  to  our  coil,  our  difficulty  would  in  a  measure  be 
solved.  It  was  actually  solved  in  the  simple  switch-board 
shown  here,  which  is  fixed  by  the  side  of  the  X-ray  installation,, 
and  conveniently  placed,  so  that  the  switching  off  of  the  lights- 
and  closing  of  tfie  primary  switch  can  be  easily  done.  I  found 
that  the  demand  of  the  small  self-induction  was  30  amp.  A 
board  was  made  for  me  by  Maison  Gaiffe,  of  Paris,  with  24 
50  C.P.  carbon  lamps  in  parallel,  with  separate  switches  to  each 
four  lamps  to  switch  them  in  gradually,  the  supply  being  con- 
nected to  the  arrival  supply  to  the  X-ray  plant.  To  design  a 
board  suitable  for  any  given  installation  it  is  necessary  to  know 
the  demand  made  upon  the  main  when  operating  the  low  self- 
inductance  of  the  coil,  and  to  put  in  the  number  of  lamps- 
required;  four  50  C.P.  carbon  filament  lamps,  at  no  V.,  con- 
sume about  5  amps.  So  it  is  easy  to  determine  the  number 
of  lamps  necessary. 

In  all  installations  of  this  kind  it  is  necessary  to  fix  a  protec- 
tion condenser  to  the  dynamo. 

The  accompanying  diagram  will  illustrate  the  connections, 
for  the  switch-board. 

To  operate  the  board,  throw  in  the  knife-switch  d  to  the 
right,  and  switch  on  the  first  four  lamps.  As  each  set  of 
lamps  is  put  into  the  circuit,  there  is  a  temporary  drop  in  the 
voltage ;  as  the  machine  speeds  up  the  voltage  rises  to  its- 
original  value,  and  then  further  lamps  are  switched  on.  In 
the  case  shown  in  Illustration  42,  when  all  the  24  lamps  are- 
burning  at  full  pressure  the  dynamo  is  giving  an  additional' 
30  amps,  at  no  volts,  which  is  now  at  our  disposal.  If  the 
knife-switch  <af  is  now  thrown  over  to  the  left,  the  lamps  are 
cut  out  of  the  circuit,  and  the  whole  30  amps,  is  thrown  into- 


X-Ray  Observations  for  Foreign   Bodies         75 

the  small  induction  prmiary  of  the  coil,  which  will  then  give 
a  current  in  the  secondary  several  times  larger  than  is  obtain- 
able in  the  normal  working  of  the  dynamo.  When  the 
exposure  is  finished,  the  switch  is  thrown  back  to  the  right; 
and  if  the  heavy  current  is  not  further  needed,  the  lamps  are 
cut  out  gradually  by  means  of  the  small  switches. 

A  voltmeter  is  an  essential  part  of  the  installation,  and  must 
be  mounted,  should  there  not  be  one  already,  so  as  to  check 
the  rise  and  fall  in  pressure. 


76         X-Ray  Observations  for  Foreign  Bodies 


APPENDIX  11. 

RADIOGRAPHS  DIRECT  ON  BROMIDE  PAPER  AND 
THEIR  PLACE   IN  WAR  ECONOMY. 

Limitations  of  Bromide  Paper. 

It  should  be  understood  from  the  beginning  that  the  use 
of  bromide  paper  to  replace  plates  in  radiography  is  limited. 
It  is  absolutely  unsuited  for  fine  detail  and  the  diagnosis 
necessitating  fine  detail,  such  as  injuries  to  joints,  doubtful 
fractures,  bone  diseases,  sequestra,  etc.  For  it  must  be  recog- 
nised beyond  all  doubt  that  a  radiograph  direct  on  bromide 
paper,  or  a  print  from  a  negative,  viewed  as  it  is  by  reflected 
light,  can  never  show  delicate  gradations  of  tone  and  detail 
like  a  plate  viewed  by  transmitted  light.  It  is  admitted,  then, 
that  plates  (or  films)  are  imperative  for  fine  diagnostic  work, 
but  all  war  radiography  is  not  of  this  kind.  Civil  practice  is 
largely  so,  and,  as  a  result,  many  radiographers  are  grossly 
prejudiced  against  bromide  paper,  and  fail  to  see  its  use  and 
advantages  in  certain  branches  of  war  radiography.  Never- 
theless, direct  bromide  radiographs  have,  beyond  doubt,  a 
field  all  their  own  from  the  point  of  view  of  efficiency  and 
economy.  Illustrations  51,  52,  53  and  54  suggest  the 
possibilities. 

Indications  for  Use,  . 

There  are  two  large  demands  made  on  the  radiographic 
service  which  bromide  paper  can  admirably  fill,  namely,  the 
demonstration  of  foreign  bodies  and  of  fractures. 

At  the  advanced  field  hospitals  many  fluoroscopic  observations 
are  made  for  both  these  purposes — a  search  for  foreign  bodies, 
and  an  examination  for  the  position  and  nature  of  fractures, 
and  the  alignment  of  fragments.  A  large  percentage  of  such 
work  is  on  the  limbs,  and  the  routine  varies  with  different 
units.  In  many  cases,  most  of  the  fluoroscopic  observations 
are  followed  by  a  plate,  and  a  report  is  made,  upon  which  the 
subsequent  operation  and  treatment  are  based.  Evacuation 
of  the  patient  follows,  with  a  report  (often  ambiguous  and 
conveying  little  to  the  medical  officer  who  receives  the  case) 
of  the  condition  that  led  to  the  treatment  or  operation 
practised,    such    as    resection,    sequestrectomy,    etc.       What 


X-Ray  Observations  for  Foreign   Bodies         ']'] 

would  the  medical  officer  receiving  a  case  not  give  to  see  the 
radiograph  upon  the  evidence  of  which  the  tieatment  has 
been  practised?  What  would  not  be  gained  in  judgment, 
progress,  and  results,  wei'e  the  radiographic  records  complete 
in  every  case  ?  Patients  are  perforce  at  times  evacuated 
before  their  plates  are  dry;  bromide  radios  can  be  blotted, 
and  dry  very  cjuickly. 


Illustration  51. 

Antero-posterior  and  lateral  direct  radiographs  on  bromide  paper. 

These  pictures  give  an  idea  of  the  amount  of  detail  that  can  be  obtained. 

Sequestra,  osteomyelitis  and  rarefying  osteitis  are  well  demonstrated. 

I  submit  that  here  is  the  place  for  direct  bromide  radios. 
At  the  tiine  of  these  first  injuries  in  the  shaft  of  the  bones 
there  are  few  line  details  to  diagnose;  large  sheets  of  bromide 
paper  may  be  used,  and  this  has  the  advantage  of  including 
the  articulations  at  both  ends,  which  will  then   disclose  the 


78         X-Ray  Observations  for  Foreign  Bodies 

nature  and  the  degree  of  any  displacement  present.  Antero- 
posterior and  lateral  views  may  be  taken  side  by  side  on  the 
same  sheet.  The  development  takes  but  a  minute;  and  as  the 
saving  of  time  and  labour  at  the  front  is  important,  during  a 
rush  of  work,  this  is  a  great  gain;  moreover,  if  so  desired,  the 
time  saved  can  be  used  to  make  prints  from  negatives,  where 


Illustration  52. 

Radio  for  position  of  fragments.     Femur. 

Bedside    radiograph  taken  with  portable  apparatus  passing  2  M.A.,  42 

M.  A.S.     Penetration  equivalent  to  35  inch  spark-gap,  distance  22  inches. 

plates  have  been  necessary  to  decide  as  to  the  involvement  of 
a  joint.  When  so  made  these  radios  complete  the  records  of 
the  case,  by  providing  the  earlier  observations  which  are  so 
fi-equently  absent. 

There  are  still  many  surgeons  who  prefer,  in  spite  of  the 


X-Kay  ObstTvatioiis  for  Foreign   Bodies         79 

mathematical  accuracy  of  improved  localisation  methods,  to 
operate  for  the  removal  of  foieign  bodies  by  the  informati(jn 
gained  from  antero-posterior  and  lateral  plates;  ov  it  may  be 
desirable,  in  conjunction  with  a  localisation,  to  record  the 
relationship  of  a  foreign  body  to  some  bony  landmark  in  a 
radiograph.     For  these  purposes  the  use  of  plates  is  unwar- 


lUustration  53. 

Radio  of  humerus  for  position  of  fragments,    Antero-posterior  and  lateral. 

Taken  in  bed.     Portable  apparatus  passing  2  M. A.  18  M.A.S.     Equivalent 

spark-gap  25  inches,  distance  17  inches. 

ranted  extravagance,   bromide  paper  giving  in  every  respect 
the  same  information. 

To  follow  our  patient  a  stage  further,  the  next  demand  on 
the  department  is  to  verify  the  position  of  the  fracture  on 
admission  to  a  hospital  ;  and  should  he  be  transferred  to  an 


8o         X-Ray  Observations  for   Foreign  Bodies 

apparatus  for  treatment  by  extension  and  suspension,  he  will 
need  to  be  radiographed  in  the  apparatus  as  he  hes  in  bed;  it 
is  well  known  that  an  extra  kilo  in  extension  pull,  or  a  slight 
change  of  angle,  may  mean  all  the  difference  between  a  fair 
and  an  excellent  result.  For  this  work  bromide  paper  is  ideal; 
sheets  may  be  used  large  enough  to  include  the  articulations, 
with  antero-posterior  and  lateral  radiographs  on  the  same 
sheet,  as    before   mentioned,  and    in  this  way   the   results  of 


Illustration  54. 
Direct  bromide  radiograph  of  hip-joint,  65  M.A.S.,  equivalent 
spark-gap  4  inches,  distance  20  inches. 

treatment  may  be  checked  so  as  to  give  the  best  possible 
result  in  the  alignment  of  the  fracture. 

When  the  time  comes  for  final  results,  these  can  again  be 
radiographed  on  bromide  paper,  so  as  to  complete  the  papers 
of  the  case. 

Where  it  is  desired  that  one  radiograph  shall  be  retained 
and  a  second  shall  go  with  the  patient's  papers,  two  bromide 
radios  can  be  taken  at  the  same  time,  as  explained  below  under 
technique. 

All  these  observations  can  be  made,  compiling  valuable  data 
and  ensuring  the  best  results  obtainable,  and  at  the  same  time 
the  expenditure  involved  will  be  only  a  tithe  of  the  cost  of 
the  plates  that  are  saved. 

From  time  to  time  radiographs  will  be  needed  to  determine 


X-Ray  Observations  for  Foreign  Bodies  8i 

■the  presence  of  sequestra,  osteomyelitis  etc.     For  this  work 
jiothing  short  of  the  best  plates  and  films  will  suffice. 

Technique. 

The  bromide  paper  should  be  the  most  rapid  positive  paper 
that  can  be  obtained  (of  the  carbon  or  contrast  type),  and  a 
surface  about  the  same  as  that  of  a  plate  is  to  be  preferred  to 
an  enamel  surface. 

Intensification  Screens  should  always  be  used,  not  only  on 
account  of  the  reduction  of  the  exposure,  but  because  the 
print  is  of  a  far  better  quality,  being  richer  in  detail  and 
•contrast. 

The  tube  penetration  should  be  about  15  to  20  per  cent, 
less  than  the  recognised  penetration  for  plates.  Too  hard  a 
tube  makes  the  print  foggy  and  flat.  Suitable  penetration  is 
an  important  factor. 

The  exposure  will,  of  course,  vary  with  different  papers  ;  it 
should  be  approximately  from  |  to  |  of  that  required  for  a  plate 
under  the  same  conditions,  but  without  a  screen.  Over- 
•exposure  is  to  be  avoided.  The  best  exposure  can  be  soon 
found  with  any  special  paper. 

Development  is  another  important  consideration.  If  metol 
hydroquinone  developer  is  being  used  for  plates,  and  it  usually 
is  so,  it  will  answer  perfectly  for  these  prints  ;-  in  this  way  no 
extra  dishes  or  solutions  are  necessary.  Some  extra  bromide 
is  the  only  addition  needed. 

Development  is  complete  in  from  one  to  two  minutes,  and 
-several  prints  can  be  developed  at  the  same  time,  which  should 
be  appreciated  when  there  is  a  rush  of  work. 

If  two  copies  are  needed,  two  screens  in  the  one  cassette  at 
"the  same  time  will  meet  the  case,  and  little  difference  can  be 
observed  in  the  resulting  radiographs.  It  is  not  necessary  to 
have  special  screens  for  the  smaller  sizes,  as  the  bromide  paper 
for  radiographs  of  the  long  bones  can  be  cut  in  halves  length- 
ways and  placed  in  the  cassette,  without  any  risk  of  scratching 
the  screen,  as  plates  so  used  would  do.  If  at  a  later  date 
-extra  copies  should  be  required,  photographic  copying  on  the 
same  or  a  reduced  scale  may  be  resorted  to.  Intensification 
may  be  practised  if  a  print  needs  strengthening.  If  so  desired, 
a  print  may  be  treated  with  wax  and  used  to  print  from  in  the 
same  manner  as  a  glass  negative.  Such  treatment  is  really 
superfluous,  as  excellent  contact  prints  can  be  made  without 
any  preparation. 


X-Ray  Observations  for  Foreign  Bodies 


Stereoscopic  radiographs,  made  with  the  usual  technique  of 
tube  displacement,  can  be  viewed  with  a  Pierre  stereoscope,  or 
if  this  useful  little  instrument  is  not  on  hand,  resort  can  be 
made  to  the  mirror  bisector  principle  (see  p.41.  Illustration  31). 
For  the  production  of  radiographs  to  be  so  viewed,  the  rays 
pass  in  the  first  exposure  through  the  bromide  paper  to  the 
screen,  and  in  the  second  through  the  screen  to  the  bromide 
paper. 

For  economy  in  radiography  of  the  long  bones  half  sheets 
may  be  used. 


N 


Illustration  55. 

Stereo  radios  direct  on  bromide  paper.     Technique  of  production. 
Single  copy. 

A.  Central  position  of  tube.    A'  A".  Displacements  right  and  left. 
PL.  Patient's  limb.     C.    Stereoscopic  cassette  carrier.    LS.  Lead 

sheet.    BP.  Bromide  paper.    S.  Intensifying  screen. 
Inset,  Position  of  screens  and    bromide  paper  for  production    of 
duplicates. 

If  duplicates  are  required,  two  screens  and  two  sheets  of 
bromide  paper  may  be  suitably  arranged  in  the  cassette,  so  that 
the  rays  pass  through  one  sheet  of  bromide  paper  to  the  first 
screen,  and  through  the  second  screen  to  the  second  sheet  of 
bromide  paper. 

The  radiographs  are  afterwards  cut;  the  left  half  of  the  first 
and  the  right  half  of  the  second  form  a  stereoscopic  pair,  as  do 
also  the  remaining  two  half  sheets.     If  only  one  stereoscopic 


X-Ray  Observations   for  Foreign   Bodies         83 

copy  is  needed,  a  screen  may  be  cut  in  halves  and  kept  specially 
for  the  purpose  ;  the  half  screens  and  the  bromide  half  sheets 
are  placed  side  by  side  in  the  cassette,  the  paper  lying  on  top 
of  the  screen  on  one  side,  and  the  screen  on  top  of  the  paper 
on  the  other.  (See  Illustration  55.)  The  two  halves  are 
exposed  in  turn,  one  half  during  each  exposure  being  covered 
with  lead,  as  explained  above  (pp.  41,  42). 

The  arguments  in  favour  of  the  use  of  bromide  paper  may  be 
briefly  summed  up  as  follows: — Glass  is  getting  increasingly 
scarce,  and  old  negative  glass  used  over  again  produces  an 
unsatisfactory  plate.  The  breakage  of  plates  in  transport  and 
in  the  department  is  considerable;  weight,  packing,  space,  and 
labour  of  transport  are  serious  questions,  cost  being  last  but 
not  least. 

In  contrast,  100  sheets  of  bromide  paper  occupy  less  space 
and  weigh  less  than  six  plates,  a  great  economy  of  money,  time, 
and  material  is  effected,  and  the  radiographs  can  accompany 
the  patient  and  make  his  history  complete.  Large  radiographs 
can  be  taken  more  frequently  to  determine  the  position  of  a 
fracture,  thus  greatly  increasing  the  efficiency  of  treatment, 
and  improving  the  results,  since  the  cost  at  present  renders  the 
free  use  of  plates  for  this  purpose  impossible. 


INDEX. 


Amplification  of  cross  section  chart  ... 
Anatomical  densities 

eye  localisations 

localisation,  general    ... 

source  of  error 

their  variations 

Belot,  Dr.,  ej'e  localisation  method  ... 
Bromide  paper 

economyof     ... 

indications  for  use  of 

limitations  of 

technique 

use  of 

Chart,  production  of,  for  localisations 
amplification  of 
triangulation  method,  production  from 
value  of 

Debierne's  localisation  method  ...    . 

Department,  X-ray — 

lighting  of,  size,  ventilation     ...     . 

position  of 
Dessanne,  cryptoscope  ...  ...  . 

Diaphragm,  types  of,  necessity  of 

fluoroscopy  of 

foreign  bodies  in  region  of       .... 


Equipment,  general 
Eye,  foreign  bodies  in 

anatomical  localisation  of  (Dr.  Belot's  method) 

general  observations  of 

localisation  of,  by, triangulation 

muscles,  foreign  bodies  in 
localisation  of 
Eyelid,  foreign  bodies  in       ...  ... 

Finger  cot,  magnetic 

Fluoroscopic  control  at  operatian,  arrangements,  lighting,  and 

technique 
Fluoroscopy — 

general  technique 

variation  of  penetration,  value  of 


PAGE' 

... 

52 

T 

... 

24 

35, 

52- 

7 

7 

26 

17 

17 

76 

76 

81 

IT 

47 

51 

52 

51 

54 

40 

2 

60 

62- 

3 

37 

39- 

37 

39 

1 

24 

26. 

25 

24 

26- 

33, 

35 

•  •• 

26 

70- 
60- 

36- 
8: 


•86  Index 

PAGE 

Foreign  bodies — 

general  search,  necessity  of     ...  ...  ...  ...  7 

nature  of ,  appearance  on  plate  and  screen  ...  ...  4 

pitfalls  and  possible  errors       ...  ...  ...  ...  5 

wood,  the  shadow  it  casts        ...  ...  ...  ...  4 

'Geometrical  localisation       ...           ...  ...  ...  ...  19 

Head,  foreign  bodies  in        ...            ...  ...  ...  ...  55 

localisation,  special  technique  of  ...  ...  ...  55 

Heart,  foreign  bodies  near    ...            ...  ...  ...  ...  37 

Hirtz  compass         ...            ...            ...  ...  ...  ...  60 

Intensifying  screens — 

source  of  error  if  faulty            ...  ...  ...  ...  5 

use  with  bromide  paper           ...  ...  ...  ..  81 

-Localisation  of  foreign  bodies — 

antero-posterior  and  lateral  plates  in    ...  ...  ...  16 

apparatus  for               ...           ...  ...  ...  ...  40 

charts  of        ...  ...  ...  ...  ...    13,53,55,56 

compasses  for               ...            ...  ...  ...  44,49 

Debierne,  localisation  method  ...  ...  ...  49 

eye,  foreign  bodies  in               ...  ...  26—35 

heart,  foreign  bodies  near        ...  ...  ...  37 

head,  foreign  bodies  in             ...  ...  ...  ...  55 

Hirtz  pierced  screen    ...            ...  ...     '       ...  ..  18 

in  thorax        ...            ...           ...  ...  ...  ...  36 

intersecting  lines,  by .. .            ...  ...  ...  ...  42 

modification  of     ...            ...     .      ;..  ...  ...  50 

Mackenzie  Davidson,  method  ...  22 

mechanical  appliances  for         ...  ...  ...  ...  21 

oblique  rays,  use  of,  in           ...  ...  ...  36 

of  wound  tract  ...  ...  ...  frontispiece,  h^ 

provisional            ...            ....  ...  ...  ...  10 

stereoscopic  tracings  ...            ...  ...  ...  ...  13 

value  of  ...            ...            ...  ...       '■'-...'■  39 

Strohl  apparatus  and  method  ...  ...  ...  ...  11 

triangulation method  ...            ...  ...  ...  ...  19 

^Mechanical  localisers            ...      :      ...  ...  ...  ...  21 

diaphragms    ...            ...            ...  ...  3 

guidance  at  operation               .....  ...  ...  ...  56 

skin  markers              ...            ...  ...  10,11 

J^ormal  ray,  importance  of,  how  to  obtain,  record      ...-  ....  7 

Penetration,  value  Of  variation          ...  ...  ...  ...  3,4 

Photographic  faults,  frequent  cause  of  error  ....  ...  5 

Protection — 

absolute  necessity  of ,  testing  of  ...  ...  ...  2 

patient,  protection  of               ...  ...  ...  •••  50 


Index 


87 


Radiography— 

antero-posterior  and  lateral  plates,  technique  of 

...      16- 

.     fluoroscopy,  confiiTnation  by    ... 

7 

short  exposures,  aid  to 

...       72 

stereoscopic    ... 

40,  41,  83 

Short  exposures,  aid  to 

...       72. 

Skin  markers — 

materials 

...       10' 

mechanical  devices     ... 

...       11 

Stereoscopic- 

apparatus 

...       40- 

bromide  radiographs  ... 

...       82 

localisation    ... 

...     m- 

tracings 

...       13. 

Strohl's  localisation  method 

...     11 

Sutton's  probe,  description,  use  of    ... 

...       65 

Telephone,  electric  ... 

..       69- 

Tracings — 

localisation     ... 

..       15 

stereoscopic  ... 

...       13: 

use  of 

...       16 

Tube- 

centering  of,  importance  of 

8 

devices  for 

9,10 

choice  of,  care  of,  focus  of 

3 

Coolidge,  advantages  of 

a 

Vibrator,  Bergonie 


6& 


London : 

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